VATI GREENLIGHT PREDICTOR 2022-2023 REAL EXAM 180 QUESTIONS AND CORRECT ANSWERS(VERIFIED ANSWERS)|AGRADE

A nurse has delegated care to an assistive personnel. At the end of the shift, the Ap asks the nurse to enter data for her because the AP has forgotten her password and needs to leave. Which of the following actions should the nurse take?
Tell the AP to contact the IT department for charting assistance.

A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The nurse should instruct the parents to place the car seat in a….
Rear-facing position in the back seat.

A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?
contact security personnel to place the money in the facility safe.

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 on hemorrhage?
Frequent Swallowing

A nurse is reinforcing discharge teaching with an older adult client’s family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include?
Instruct the client to bear down during rectal tube insertion.

A nurse is caring for a client. Which of the following client statements should the nurse attend first?
“My heartburn pain is going into my jaw now”

A nurse is caring for a client who is 3 days postoperative following abdominal surgery and has a Penrose drain. Which of the following actions should the nurse take?
Leave the drain insertion site open to air

A nurse is reinforcing with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?
“You will have to drink a contrast medium before the test.”

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of burn. Which of the following findings should the nurse expect?
Hypernatremia

A nurse is planing to administer an ophthalmic medication to a client. Which of the following actions would minimize systemic absorption of the medication?
Wait 5 mins after instillation before instilling the drops in the other eye

A nurse is preparing morning medication for a client who has potassium level of 3.2 mEq/L. For which of the following medications should the nurse withhold administration and notify the provider?
Furosemide

A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider?
Facial flushing

A nurse in a provider’a office is collecting data from a client who was discharged from the hospital 7 days ago following treatment from deep-vein thrombosis. Which of the following findings is the nurse’s priority?
The client takes ibuprofen to treat musculosketal pain.

A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?
Muscle weakness

A nurse is participating in a performance improvement process to decrease the rate of health care-associated infections within the facility. The nurse should recognize that which of the following is an appropriate performance improvement outcome indicator?
Client data indicates a decreased rate of infection

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the clients’s right leg should be of the most concern to the nurse?
The client’s foot feels cooler than the previous assessment

A nurse is preparing a client regimen. Which of the following insulins can be mixed?
Aspart
Regular
Detemir
Lispro
Glargine cannot be mixed with any insulin

A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following?
Vitamin D

A nurse is reinforcing teaching with a postpartum client. Which of the following should the nurse explain as the most important reason for staff to wear identification?
Reducing the risk of newborn abduction

A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by the 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 on a mental health unit is discussing client rights with a group of coworkers. Which of the following statements should the nurse include?
A nurse must withdraw consent for treatment in writing if he is competent to do so.

A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24hr ago

A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
Document in the client’s medical record every 15 mins

A nurse is reinforcing teaching with the family of a client who is receiving palliative care for terminal cancer. Which of the following guidelines should the nurse emphasize about appropriate pain control measures?
Administer schedule doses of medication from a patient-controlled analgesia (PCA) pump.

A nurse is assisting with a group therapy session in which a client begins to monopolize the group’s time. Which of the following interventions is appropriate?
schedule one-on-one discussion time with the client

A nurse is preparing to administer required immunization to a toddler during a well-child visit. The parent ask the nurse how many baby aspirin he should administer if the toddler develops a fever. Which of the following responses should the nurse make?
“You should avoid administering aspirin to your child”

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?
Document the client’s risk in the medical record.

A nurse is assisting with the admission of a client who has Hodgkin’s disease and is receiving chemotherapy. Because a private room is not available, the nurse should recommend that the client share a room with a client who has which of the following diagnoses?
Sickle-cell anemia

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child’s siblings should the nurse expect?
The school-age sister views death as being a type of temporary sleep

A nurse is reinforcing teaching with a client about the importance of a low-sodium diet. Which of the following foods should the nurse recommend as the best choice to include in a low-sodium diet?
medium baked potato

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy?
Serum calcium 12.5 mg/dL

A nurse is caring for a client who is asking about the technique of effleurage 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 in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching?
“Apply the patch to the lower abdomen.”

A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
The toddler can say four words.

A nurse in an acute mental health facility observes a client having a panic attack. Which of the following interventions should the nurse implement first?
Instruct the client to use abdominal breathing.

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)
Pallor in the exposed portion of the left foot

Inability to move the left foot

Paresthesia in the left foot

A nurse in a provider’s office is talking on the phone with the parent of a school-age child who has varicella. The parent asks the nurse when the child can return to school. The nurse should tell the parent that which of the following is an indication that the longer contagious?
All lesions are healed.

A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?
Methylergonovine

A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is the best indication that the client needs PRN pain medication?
The client reports pain.

A nurse is reinforcing healthy eating habits for an older adult client to ensure adequate dietary intake. Which of the following is an appropriate recommendation?
Snack between meals.

A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take?
Secure the restraint with an easy-to-release tie.

A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open-angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions?
“I will ask to work the night shift, so I will not be driving in bright sunlight.

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take?
Frequently remind the client of the expectations for her behavior.

A client who is prescribed metoprolol for hypertension tells the nurse, “I don’t want to take this medication because it makes me tired all the time.” Which of the following is the appropriate response?
“Let’s talk with your doctor about other options.”

A nurse is reinforcing teaching with a client who has rheumatoid arthritis and is using a straight-legged cane for ambulation. Which of the following instructions should the nurse include?
“Move the stronger leg forward first.”

A nurse is assisting with the plan of care for a client who has Alzheimer’s disease. Which of the following actions should the nurse recommend for the plan of care?
Orient the client to time and place twice per day.

A nurse is speaking to a client who called the provider’s office to report chest pain and requests clarification on how to take his sublingual nitroglycerin tablets. Which of the following instructions should the nurse give the client?
Wait 5 min between doses.

A nurse is caring for a client who is undergoing evaluation for a thoracic aortic aneurysm. Which of the following findings should make the nurse suspect an impending rupture of the aneurysm?
Report of sharp pain in the back

A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?
“I will apply cold compresses when my joints are painful.

A nurse is caring for a client who has COPD. The client tells the nurse, “I get short of breath during meals. It is too much trouble to eat.” Which of the following instructions should the nurse suggest?
“Have several small meals during the day.”

A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?
Strain the client’s urine.

A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?
Intradermal

A nurse monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?
Urticaria

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?
Urticaria

A nurse is reinforcing teaching with a client who has a new prescription for lithium carbonate. Which of the following client statements indicates an understanding of the teaching?
“I will notify my provider if I develop a tremor.”

A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Periorbital edema

A nurse is caring for a client who is postoperative following a femoral cardiac catheterization. Which of the following actions should the nurse take during the first 30 min?
Compare the bilateral peripheral pulses.

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client does which of the following?
Lists sweating, shaking, and palpitations as symptoms of hyperglycemia

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse include in the plan of care?
Decrease the level of environmental stimuli

A nurse is contributing to the discharge plans for four clients. The nurse should identify that which of the following clients requires an interdisciplinary care conference?
A client who has hemiparesis and lives alone

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 in the preparation of an in-service for a group of unit nurses about ethical principles. Which of the following nursing actions should the nurse include as an example of fidelity?
A nurse keeps a promise made to a client.

A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?
“I will apply petroleum jelly to the penis with each diaper change.”

A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
A decreased level of consciousness and vomiting

A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and drainage for cellulitis on the left arm. Which of the following techniques should the nurse use?
Help the child put a dressing on a doll.

A nurse is contributing to the discharge plan of an older adult client who had a total hip arthroplasty. The client is unable to ambulate independently and lives alone. Which of the following settings should the nurse recommend for this client?
Home health nurse visits

A nurse working on a mental health unit is meeting with a client who has been on the unit for 2 days. The nurse greets the client and asks, “What has been happening with you today?” Which of the following therapeutic techniques is the nurse using?
Giving broad openings

A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel?
collecting a stool speciment ot test for occult blood.

A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report?
A client is found lying on the floor next to a chair.

A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan?
refer the client to a diabetic support group.

A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monitor?
Clammy Skin

A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse. which of the following client statements indicate an understanding of an appropriate strategy?
“I need to recognize the signs that my husband is becoming abusive.”

“I need to identify what triggers my husband’s anger to prevent his abuse.”

A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP) has not documented the client’s blood glucose level. Which of the following actions should the charge nurse take first?
Determine if the AP has completed the assignment.

A client is scheduled for an outpatient colonoscopy. which of the following actions is a nursing responsibility in the informed consent process?
Verify that there is a signed and witnesses consent form in the client’s chart.

A nurse smells alcohol on the breath of an assistive peronnel (AP) during report. Which of the following actions should the nurse take?
Report the situation to the nurse manager.

A nurse in a provider’s office is collecting data from a parent of an infant who is being screened for cyctic fibrosis. Which of the following supports a diagnosis of cystic fibrosis?
Frothy stools.

When caring for an assigned group of clients, the nurse should wear gloves when…
performing oral hygiene.

A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration?
Subcutaneously.

A nurse is caring for a client and recognizes the client’s rights to confidentiality have been breached in which of the following situations?
A hospital risk manager includes information from a client’s medical record in

A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take?
Notify the charge nurse of the finding.

A nurse is caring for a full-term newborn who was circumcised 6 hrs. ago. Which of the following findings indicates that the newborn is experiencing pain?
Awakens every 3 hours
Furrowed Brow
Oxygen Saturation of 95%
Positive babinski reflex.

A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching?
“My doctor should decide if my organs will be donated.”

A nurse is preparing to administer an IM injection to a client. To reduce the risk of neddlestick injury, the nurse should
dispose of the used needle immediately in a puncture-proof sharps container.

A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first?
Elevate the head of the client’s bed.

A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?
Obtain verbal consent from the client while waiting for the parents to arrive.

Witness the signature of the client’s parent when he arrives.

Have the client’s older sibling give consent if a parent is not available.

Delay the procedure if the provider cannot contact the parents.

A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid?
Ice Cream

A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing. Which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases?
“This will indicate how much acid is building up in my blood.”

2 hrs post-op following an ileal conduit procedure bladder cancer
Dusky-colored stoma

Administering an INJ to a client even after the client states, “I don’t want that injection. The last time I got that I was sore for a week.”
Battery

Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take?
Observe the client’s level of mobility

Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG
Explain that the client may not have coffee prior to the EEG

Adolescent who has cystic fibrosis and has a prescription for pancrelipase
Take w/ meals

After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care?
Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2

After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP.
Set up a room for an expected postoperative admission

AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment
Redirect the AP to discuss the issue with the other AP

Assessing client who systemic lupus erythematous SLE which of the following is an expected findings
Dry, raised facial rash

At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports
Indigestion

Benefit from a three-way indwelling catheter
Prone to development of blood clots un the urine

Caring for a client who has a new prescription for chlorpromazine by IM injection
Check orthostatic BP 1 hr after admin

Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse “Am I dying?”
Admin pain meds

Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant – which pt the nurse should NOT be assigned to?
60 yr old who is recovering from shingles

Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first?
10 yr old who has pneumonia & is receiving respiratory txs

Child who has pediculosis capitis
store non-washable items in plastic bags for 14 days

Child who is unresponsive has ICP
Pad the side of the bed

A client ask the nurse if it is safe for him to take glucosamine supplement?
Shellfish allergy

Client following an open colectomy
Uncontrolled pain

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions?
Immobilizing the affect extremity

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.
Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact

Client recovering from closed head injury assumes a decerbrate posture in response to stimuli
D lying flat ?? (Extentend extremities) The client rigidly extends his arm

Client reports chest pain. Which of the following lab findings indicates myocardial damage
Troponin 1.8

Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg
Realign the extremity in traction

Client who has given birth to a stillborn
Acknowledging the reality of the newborn’s death

Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea
Admin an antiemetic (Aprepitant for nausea)

Client who is 8hr postoperative following a right-modified radical mastectomy – which findings to report to provider? (SATA)
Coughing
Frothy, pink secretions

Client who is receiving a controlled epidural analgesia infusion
Covering the insertion site with a transparent dressing

Client who reports the use of chondroitin and glucosamine
Improve joint functioning

Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house
Review the effects of secondhand smoke w/ family members

A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic
Determine the client living situation

A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office – Who to see first?
An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights

Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process
Decreased blood oxygenation

Delegates the following tasks to the AP bathe four clients, distribute fresh water, obtain morning vital signs
Set a clear time frame for the completion of each task

DI w/ severe head injury
Urine output 250

Diagnosis of antisocial personality disorder
Poor impulse control

Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration
Prepare the client for c-section

Dietary intervention for a client who is immobile due to pelvic and femur fractures
Provide a high-protein diet

Difficulty falling asleep at night
Eat a bedtime snack (containing carbohydrates??)

Disaster triage following a natural disaster
Amputation

Discharge teaching about disease prevention to a client who has active Tb
Educating the client how to cover nose and mouth with tissues when coughing

Discussing a living will with a client
It communicates my wishes for end of life care

Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism – which food not given?
Roast beef and ice cream

Education about ECT major depressive disorder
General anesthetic admin prior ECT treatments(This treatment are for pts who aren’t responding to their pharmaceutical meds)

Education to the mother of a toddler who has pertussis
Pertussis booster

An emergency department nurse triages a group of school children injured in a school bus crash
A child who reports diplopia and nausea and was unconscious at the scene but is now awake

Experiencing acute mania …
Provide high-calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down)

Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor
Contractions occur every 90 sec

Haloperidol for the tx of schizophrenia
Screen the client for Tardive Dyskinesia (inform pt to lower doses to decrease the chances of TD)

health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant’s visual field – rx?
Closes eyes

Hearing impairment – incorporate which communication methods?
Rephrase sentences the client doesn’t understand

Home health nurse is admitting a client who is prescribed peritoneal dialysis
Clarify the clients actual and perceived health needs

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system
Ask the client about her understanding of the diagnosis

A home-health nurse is providing teaching about self-administration of insulin to client who is newly diagnosed w/ diabetes mellitus
I can use the same area as long as I rotate injection sites

Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels
HbA1C

Hyperthyroidism – which of the following rooms is appropriate for the nurse to assign this client?
Cool room (reduced room temp)

If something happens to me from which I cannot recover, I don’t want to go on a ventilator:
You’re concerned that something may go wrong?

Ileal conduit due to treatment for bladder cancer
Cleanse w/ moisturizing soap

Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule
Reduces the RR

Infection control nurse is reviewing care procedures for four clients
A client who has varicella zoster is placed in a negative pressure room

In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard?
A comp. chair wheels

In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for tx of anorexia nervosa
The client will develop personalized meal plan

Involuntarily admitted to psychiatric unit following a failed suicide attempt – experimental tx
Witness consent before medication administration

Lab data on client who has dehydration
Elevated BUN

Lab values on a client who has taken an overdose of acetaminophen – organ damage
ALT

Mastitis of left breast – does this mean that i must stop nursing my baby?
No, you can continue to nurse from both your breasts

medical unit received change-of-shift report …
68 yr old

Morning lab values to several clients …
Client who is prescribed digoxin and furosemide

Pt w/ Neutropenia (MS pg. 543)
Remove fresh flowers from a client’s room

Newborn nursery is performing assessments on four neonates that are all less than 24 hr old – which pt is priority?

Pinna below the outer canthus of the eye (The eye should be even with the upper tip of the pinna of the newborn’s ear; MN p. 158)

Pt is Nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement w/ 5cm of dilation. At the end of last contraction, the nurse observes a large gush of fluid coming out of clients perineal area. What should nurse do first?
Check FHR!!

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 dx to the CDC?
Hepatitis A

A nurse at the family planning clinic triages several clients over the phone – (PRIORITY)?

Sharp pain in RIGHT shoulder

A nurse delegates tasks to a LPN and an AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube – which of the following tasks is most appropriate to delegate to the LPN?

Insert an indwelling catheter if the client has not voided in 3 hr

A nurse educator is discussing modes of transmission w/ nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission?

West Nile virus from mosquito bite

A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk w/ an adolescent client who was admitted w/ clinical depression. After a few minutes of convo, the adolescent ask the nurse “why did you choose to talk to me out of this room full of kids?”
You’re curious why I am interested in you and not the others?

A nurse in a mental health clinic is reviewing the hx and physical for a 17-yr old client who has a new dx of social phobia:
Client reports minimal alteration in performance at a part-time job

Nurse in an emergency department is assessing a client who has a nasal fracture.
Clear fluid drainage from the nares

A nurse in a pedi unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions?

Pertussis

A nurse in a provider’s office is caring for a client who has Parkinson’s Disease and has been taking levodopa for the past 5 wks. The client reports a new onset of muscle twitching – best response?

This is a manifestation of drug toxicity & may require a dosage reduction

A nurse in the emergency department is caring for a client following a motor vehicle crash – PRIORITY?

Stabilize the cervical spine

A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates VERACITY?

A nurse explains the potential risks of tx.

(Veracity = truth/not withhold all info; Fidelity = keeping promises)

A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24hr following sx, the nurse should instruct the client to do which of the following?
Intermittently place ice on the ankle (30 mins – 1 hr??)

A nurse in the PACU is caring for four post-op clients. The nurse realizes that coughing poses a risk to which of the following clients?
Thyroidectomy

(Coughing can cause incision to reopen & bleeding can occur)

A nurse is admitting a client who has chronic gout – What med should the nurse admin?
Allopurinol

A nurse is admitting an infant who has bacterial meningitis. Nursing intervention?
Minimize environmental stimuli

A nurse is admitting an unidentified female who was brought to the emergency department:
3 months

A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit:
C looks normal but lots of artifact
or
Fibs in between QRS’s

A nurse is assessing a client 1 wk after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?
Graft vs host disease

A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr
Blood is backing up in the IV tubing

A nurse is assessing a client who is 2 hrs post-op following insertion of a chest tube connected to chest drainage system as depicted in the diagram above:
Fluctuation of the fluid level chamber b (middle)

A nurse is assessing a client who is post-op following abdominal sx. States “I feel like my incision ripped open.”
Place client in Low-Fowler’s position

A nurse is assessing a client w/ schizophrenia – what is a manifestation?
Auditory hallucinations

A nurse is caring for a client following insertion of a subclavian non-tunneled percutaneous central venous catheter – What should nurse do?
Review the chest x-ray

A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??)
The client is lying in a supine position

A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer.
Keep a 3 ft distance from the radiation implant

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 lab values should the nurse evaluate?
Sodium

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 has cirrhosis of the liver:
Monitor for abdominal ascites

Nurse is caring for a client who has end stage liver disease. The daughter of the clients ask about her father’s DNR request.
Tell me your feelings bout your father’s prognosis.

A nurse is caring for a client who has heart failure and has started taking a loop diuretic:
Decreased reflexes

A nurse is caring for a client who has just returned to the unit following a bronchoscopy:
Offer oral fluids to the client

A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?
Taking walks (physical activity)

A nurse is caring for a client who is postoperative and at risk for development of DVT – Risk factor?
Prolonged bed rest

A nurse is caring for a client who is receiving enteral nutrition. What lab level should be reported?
Serum sodium of 128

A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity?

Tinnitus

P-pee (furosemide)

A-abx & aspirin

C-cancer (tamoxifen)

T-tinnitus

A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. diff – PRIORITY?

Place client on contact precautions

A nurse is caring for a client who will be receiving a transfusion of platelets – Effectiveness?
Decrease in bleeding from puncture sites

A 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 aPTT of 100 seconds – What nurse do next??
Turn off heparin drip

A nurse is caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? (SATA)
-Transfer a client from bed to chair w/ mechanical lift

-Provide postmortem care on a client who experienced cardiac arrest

A nurse is caring for a mother who was prescribed methadone during pregnancy (MN p. 183):
-Tachypnea
-Irritability
-Tremors
or
-Increased seizures, sleep pattern disturbance, higher birth wt

A nurse is caring for an infant who is being treated for dehydration – indication for further education?
-Flat anterior fontanel

(Reason: Fontanels should be soft & flat; No tears = dehydration)

A nurse is caring for a post-op client. Which of the following interventions will reduce the risk of DVT?
Apply venous plexus foot pumps

A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago.
Support the affected leg on a pillow

A nurse is discussing the z-track method to admin hydroxyzine hydrochloride w/ a newly licensed nurse – Understanding of teaching?
This technique decreases the risk of subcutaneous infiltration

A nurse is electronically documenting assessment findings for a client – How should document/assess pain?
The client reports a pain level of 6 on a scale of 0-10

A nurse is giving change-of-shift report about a client who is 36-hr post-op to another nurse:
Pain relieved by changing position

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?
“Let’s talk about what happened to you”

A nurse is planning care for a client who has a new diagnosis of HIV.
I cant seem to gain any weight

A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx – What should nurse do?
Provide the client with an alternating pressure mattress

A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Remind the client to place the cane on the unaffected side.

Rationale: Keep the cane on the stronger side of the body
1- Move cane forward 15cm
2- Then, move weaker cane forward
3- Advance stronger cane

A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy:
Place the newborn 45cm or 18 in from the light source

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections UTI:
Empty bladder before & after sexy time

A nurse is planning to change the dressings on a school-age child who has sustained multiple burns:
Apply the dressings in a proximal to distal pattern

A nurse is planning to provide community education about viral hepatitis – What info should include?
Clients who have a hx of viral hepatitis are unable to donate blood

A nurse is preparing the auscultate a client’s apical pulse at the point of maximal impulse (PMI):

5th intercostal space at the left midclavicular line

A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125ml/hr. Which of the following actions should the nurse plan to take?
Dilute the solution prior to the infusion.

Rationale: Dilute K+ and give no more than 40mEq/L of IV solution to prevent vein irritation

A nurse is providing teaching for a client who has a new prescription for lithium carbonate – (Need for further education???)
Take medication w/ milk.

Rationale: Taking lithium with food would help with decreasing GI distress

A nurse is providing teaching to the parent of a preschooler who was newly diagnosed with a latex allergy – What foods to avoid?
Bananas

A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis?
Mantoux test

A nurse is reviewing medical records for four clients – Which of the following represents appropriate documentation?
Carafate 1g PO 1hr AC

A nurse is reviewing the hx and physical of a client who has right ventricular heart failure:

Hepatomegaly (liver enlargement)

A nurse is teaching a client who has a new dx of GERD – Include in teaching?
Sleep w/ HOB elevated

A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching?
Notify your provider if you experience muscle weakness!

A nurse is teaching a client who has left-leg weakness how to use a standard walker (further education?)
Moves the left leg and walker ahead together

A nurse is teaching a client who has a low literacy level about home management of diabetes mellitus:
Show the client an educational video

A nurse is teaching a family about home hospice care:
Hospice care improves the quality of life through palliative care

A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents – What include in teaching? (SATA)
-Swallowing sounds are audible
-Stools are yellow and seedy after 7 days
-Maternal breasts become soft following feedings

A nurse is writing a plan of care for a client who is home bound and has stage 2 Alzheimer’s Disease. Which of the following should the nurse include in the plan of care?
Assist with money management

A nurse manager is making staffing assignments for the med surg unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit?
A client who is 2 days posto-op following a colon resection

A nurse manager is presenting an in-service for newly licensed nurses about advance directives:
Advanced directives must benotarized to be legally implemented

A nurse manager is presenting info to the nursing staff regarding the appropriate use of client restraints – What should be included? (SATA)
-Nurse should pad the bony prominences.

-Providers prescription should include the type of restraint to use.

-Remove or replace restraints frequently to ensure good circulation to the area

A nurse notices smoke coming from aclients room and discovers a fire in the wastebasket. After moving the client to safety what nurse do next?
Co said: Notify the facility operator

I found: Activate fire alarm

A nurse plans to ambulate a client on the third day after cardiac sx.
Premedicate the client w/ the prescribed analgesic

A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility – Which ppl can be discharged? (SATA)

1 day post op
-laparoscopic
-cholecystectomy
-temp 98

A client who has an abdominal wound and is receiving negative pressure wound therapy
Report to the nurse manager

Rationale: negative pressure wound therapy is used to reduce edema

A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize?
Pt w/ Glasgow coma????

A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected – What should nurse do?
Ask the charge nurse to assign an experienced nurse to act as a resource

A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room – What should do?
Accompany the client awayfrom the common area

Nutritional assessment on a client who has a calcium deficiency
Osteogenesis

OCD – Further education??
Teach the client to meditate about obsessive thoughts

An older adult client tells the nurse, “I thought immunizations were for kids.” The nurse informs the client that older adults should receive which of the following immunizations?
Herpes zoster vaccine

Orthopedic floor is completing the morning assessments on several clients – PRIORITY client?

24-year old male who has a casted femur fracture

Performing postmorten care on an older adult client
Place absorbent pads under the buttocks area

Rationale: Apply fresh linens w/ aborbent pads on bed and a gown

Perform wound irrigation for a client who has an open secondary wound when creating a sterile field
Hold bottle w/ the palm over …. while pouring

Postpartum unit is caring for several clients (which pt do you see first?)
1 day postpartum has not voiding in 8hrs

Preparing a client for sx and nursejust administered the preoperative injection (what is the next step or first step?) *safety question
Raise the side rails on the bed

Preparing to administer eye drops to a client:
Use aseptic technique and drop the medication into the conjunctival sac

Preparing to obtain informed consent for a colonoscopy from a client who does not speak english:
Provide a consent form in the client’s spoken language

Prescribed furosemide – indication of fluid overload???
Rales in lower lobes of lungs

Primagravida client in the emergency department at 12 weeks of gestation hyperemesis gravidarum:
1,000 mL/hr

Providing dietary teaching for a client who has a hx of nephrolithiasis – Which of the following is appropriate to include in the teaching?
Avoid foods that have high levels of oxalates

Rationale: avoid foods high in oxalate sources such as spinach, black tea, cocoa, beets, pecans, peanuts, okra etc.

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 her diet during lactation?
Calcium

Providing postoperative teaching to a client who has a newly inserted pacemaker (if for further education this maybe the answer because this is not in the education)
I will use my cellphone on the earopposite of my pacemaker

Recognizes that the teen pregnancy rate in the community has increased:
Arrange a meeting with teenage mothers who are high school students in the community

Rationale: Provide pregnancy counseling, including alternative course of actions, instructions and encourgament in parenting role in home and peer group settings.

Recovering from an acute myocardial infarction – left sided heart failure:
Bilateral lung crackles

Recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling – What could be problem?

The tubing may be kinked

Rationale: Tidaling is expected.
Cessation of tidaling in water seal chamber signals lungs re-expansion or obstruction.
Continuous bubbling indicates an air leak.

Referral for a speech language pathologist:
Client who has difficulty swallowing

Reviewing data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse?
A 3-month old infant who has a skull fracture from reportedly rolling off the changing table

“Reviewing” medications for a group of clients labor and delivery (which would you NOT give?)
Phenytoin for seizure disorder

Rising number of sexually transmitted infections in the community????
?????

School nurse scabies
Red itchy papules on child’s groin area

Several client measurements were obtained with morning vital signs – pt priority*??

A 4-year old who has closed head injury and heart rate of 60

Tetralogy of Fallot:
Pulse oximeter

Urinalysis done for a preschool age child:
Pyelonephritis ????

PRIORITY action for post-op ileus?

Monitor bowel sounds

Idenfy risks for fat embolism syndrome (FES):
Older adults (70 or older) and hip/pelvis fractures are common causes

(turn upside down)?

Disorder of eye post-op risk?
Bleeding and infection

A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the following statements indicates an understanding of the instructions?
I will feed my baby six to eight times a day

A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain,swelling, and stiffness. Which of the following client statements indicates understanding of the teaching?
I will exercise my joints as much as i can when they are inflamed

A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?
Refrain from using deodorant on the morning of the test

A nurse is preparing a clients insulin regimen. Which of the following insulin’s can be mixed?
Insulin aspart, regular insulin, insulin lispro

A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open-angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions?
I will take a stool softener to prevent constipation

A nurse is caring for a client who had a stroke and is having difficulty swallowing. The nurse should recommend a referral to which of the following members of the interprofessional team?
Speech therapist

A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?
Change the perineal pad with each void

A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the following findings should the nurse expect?
Periorbital edema

A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration?
Administer using a needless syringe in the buccal cavity

A nurse is reinforcing teaching with a client who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?
I will plan to have my meals at regular intervals

A nurse in long-term care facility has received change-of-shift report about 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 collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication?
Pinpoint pupils

A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?
Muscle weakness

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?
Depression

A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a 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 newborns head until he can hold his head up

A nurse is caring for a school-age child who has epistaxis. Which of them following actions should the nurse take?
Apply pressure at the bridge of the child’s nose

A nurse is caring for four clients. Which of the following clients statements should the nurse attend to first?
My heartburn pain is going into my jaw now

A nurse in a providers office is talking on the phone with the parent of a school-age child who has varicella.
All vesicles have crusted over

A nurse is collecting data from a client who hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?
I feel tired all the time

A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. Which of the following actions should the nurse take?
Slow the rate of instillation

A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
A decreased level of consciousness and vomiting

A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take?
Open the outermost flap of the wrapper toward the body

A nurse is caring for a client who has viral pneumonia. Which of the following actions should the nurse take?
Administer Azithromycin

A nurse who orienting to a medical-surgical unit is having difficulty finishing client care tasks during his shift. Which of the following suggestions should the nurse’s preceptor make to help the nurse with time management?
Try to complete a task before moving on to the next.

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client’s dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?
Use paper tape for securing the new dressing.

A nurse working in an inpatient mental health facility is assisting with the plan of care for a client who has anorexia nervosa. Which of the following should the nurse recommend to include in the plan of care?
Maintain continuity of staff members.

A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?
Hallucination

A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which of the following statements should the nurse include?
“Wash your newborn’s head under a stream of running water.”

A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his diet. Which of the following recommendations should the nurse provide?
Replace bottled salad dressing with homemade vinegar and oil dressing.

A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is 6 hr postpartum following a vaginal delivery. The client has an episiotomy and swelling of the labia. Which of the following instructions should the nurse include?
Sit on soft pillows throughout the day.

A nurse is caring for a client who has a new colostomy. He voices a reluctance about resuming sexual relations. Which of the following is an appropriate response by the nurse?
“I’m available if you’d like to talk about your concerns.”

A nurse is reinforcing discharge teaching about transmission precautions with a client who has hepatitis C. Which of the following information should the nurse include?
Avoid sharing razors with other family members.

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates to the nurse a need for further teaching?
“I will be sure to wear cotton socks.”

A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the following interventions should the nurse recommend?
Observe the client for 1 hr after meals.

A nurse is assisting with the discharge planning for a client following a myocardial infarction. Which of the following is an appropriate referral for this client?
Respiratory therapist for breathing exercises

A nurse is contributing to the discharge plan of an older adult client who had a total hip arthroplasty. The client is unable to ambulate independently and lives alone. Which of the following care settings should the nurse recommend for this client?
Skilled nursing facility

A nurse is reinforcing teaching with the parents of a preschool-age child who has a new diagnosis of celiac disease. Which of the following foods should the nurse recommend?
Corn tortillas with black beans

A nurse is assisting with the admission of a client who has mononucleosis. Which of the following isolation precautions should the nurse initiate?
Droplet

A nurse is caring for a client and begins to suspect he is experiencing transference. Which of the following client statements should the nurse identify as an indicator of transference?
“I feel really close to you because you remind me of my ex-boyfriend.”

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 caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client does which of the following?
States that he will treat hypoglycemic reactions with 15 g of carbohydrates

A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?
Contact security personnel to place the money in the facility safe.

A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following tasks is appropriate to delegate to an assistive personnel?
Administer a large-volume enema to a client.

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?
Hypercalcemia

A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
The toddler can say four words.

A nurse delegates a task to an assistive personnel (AP) and the AP refuses the assigned task. Which of the following actions should the nurse take first?
Perform the task.

A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?
Providing a ham and cheese sandwich to a client who follows a kosher diet

A nurse is reinforcing teaching with a client who has a vitamin C deficiency. Which of the following foods should the nurse include as having the highest vitamin C content?
1 cup raw broccoli

A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first?
A client who has diminished breath sounds and paradoxical chest movement

A nurse is working in an urgent care clinic when a client who does not speak the same language arrives with a laceration that will require suturing. Which of the following actions appropriate for the nurse to take?
Ask an assistive personnel who speaks the same language as the client to assist in obtaining informed consent.

A nurse is collecting data from a client who has dehydration and is receiving continuous IV therapy. Which of the following findings indicates effectiveness of the IV therapy?
BUN 16 mg/dL

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child’s siblings should the nurse expect?
The school-age sister is concerned about the impact of her sibling’s death on herself

A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take?
Serve meals with plastic utensils.

A nurse is removing a female client’s indwelling urinary catheter. Which of the following actions should the nurse take?
Withdraw the fluid from the catheter’s balloon.

A nurse is collecting data from a parent of a preschooler at a well-child visit. Which of the following findings is a contraindication to a measles, mumps, and rubella (MMR) immunization?
Long-term use of immunosuppressants

A home health nurse is reinforcing teaching with a client about kitchen safety. Which of the following instructions should the nurse reinforce about using a fire extinguisher?
Sweep the extinguisher from side to side to put out the fire.

A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?
“You should follow the label directions based on your child’s weight.”

A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
Request that the provider write an as-needed prescription for restraints.

A nurse is reinforcing teaching with an older adult client who has a new prescription for digoxin for heart failure. Which of the following effects should the nurse include as an expected outcome of this medication?
Increased heart rate

A nurse is assisting with the plan of care for a client who has Alzheimer’s disease. Which of the following actions should the nurse recommend for the plan of care?
Give directions using simple phrases.

A nurse is caring for a client in a provider’s office. The client asks about the purpose of a living will. Which of the following is the appropriate response by the nurse?
“It expresses your wishes regarding health care when you can no longer communicate.”

A nurse is planning to administer an ophthalmic medication to a client. Which of the following actions will minimize systemic absorption of the medication?
Wait 5 min after instillation before instilling the drops in the other eye.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse plan to take?
Don a gown and gloves when providing perineal care.

A nurse is reviewing the medical record of a client who is requesting an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptives?
History of renal calculi

A nurse collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client received 200 mL more than prescribed. Data collection reveals that the client is stable. The nurse recognizes that this incident is not considered malpractice for which of the following reasons?
The client was not harmed as a result of the incident.

A nurse is escorting a client to his car following discharge from an acute mental health facility. The client states intentions to harm a friend when he leaves the facility. Which of the following actions should the nurse take?
Prevent the client from leaving the facility.

A nurse is caring for a client who is 5 days postoperative following abdominal surgery. The client tells the nurse that he was coughing and “felt a pop” at the incision site. The nurse examines the incision and finds wound dehiscence and evisceration. Which of the following actions should the nurse take?
Place the client in a side-lying position.

A nurse receives a verbal order for a client to receive a stat dose of meperidine 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered phenytoin 100 mg PO. Which of the following actions should the nurse take first?
Check the client’s vital signs.

A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first?
Repeat the test on another finger.

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
withdraw 5 units of regular insulin from the vial.

A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?
Strain the client’s urine.

A nurse is observing the mother of a 12-hr-old newborn. Which of the following actions by the mother requires intervention by the nurse?
The mother places the newborn in prone position.

A nurse in a mental health facility is reviewing the laboratory reports for four clients. Which of the following results should the nurse report to the provider immediately?
Sodium level of 130 mEg/L for a client who has bipolar disorder and takes lithium

After receiving change-of-shift report, which of the following clients should the nurse collect data from first?
A client who has heart failure and reports severe dyspnea

A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?
“You will receive an injection of contrast dye during the test.”

A nurse is evaluating a client who just attended a breastfeeding class. Which of the following statements by the client demonstrates that she has understood the teaching?
“I will feed my baby each time he cries.”

A nurse is preparing morning medications for a client who has a potassium level of 3.2 mEq/L. For which of the following medications should the nurse withhold administration and notify the provider?
Furosemide

A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider?
Ketones positive

A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?
Place the client in a room that is ventilated to the outside.

A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?
“You feel upset by the responses of others.”

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy?
Serum calcium 12.5 mg/dL

A nurse in the newborn nursery is planning to obtain blood from a newborn by a heel stick. Which of the following actions should the nurse plan to take?
Apply a heat pack 5 to 10 min prior to the procedure.

A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24 hr ago

A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using?
Rationalization

A nurse working at a crisis hotline call center receives a call from a client who states, “I cannot take it. My life is over.” Which of the following is the priority response by the nurse?
Are you thinking of harming yourself?”

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 caring for a 17-year-old client who admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?
Delay the procedure if the provider cannot contact the parents.

A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?
Call EMS if a seizure lasts 5 min or more.

A nurse in a mental health unit asks a client who has schizophrenia, “How are you?” Which of the following responses should the nurse identify as the speech alteration of echolalia?
“How are you?”

A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use?
FLACC scale

A nurse is caring for a client who has a new prescription for furosemide. The client asks the nurse about the purpose of the medication. The nurse tells the client, “This medication is a diuretic, and you should monitor your weight while taking it.” Which of the following ethical concepts is the nurse exhibiting?
Veracity

A nurse is expressing concern about his assignment with the charge nurse. The nurse states that he has more work to do than anyone else. Which of the following statements by the charge nurse demonstrates the conflict resolution strategy of competing?
“We will take a look at the assignments together and attempt to modify the workload you are concerned about.”

A nurse discovers a fire in a trash can in a client’s room. Which of the following actions should the nurse take first?
Walk the client to the waiting room.

A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. Which of the following is an appropriate response by the nurse?
“You have the right to refuse the recommended treatment plan.”

A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of the following statements by the client indicates an understanding of the information?
“I will have a chest x-ray following the procedure.”

A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of the following statements by the client indicates an understanding of the teaching?
“I will remove my microwave oven from my home.”

A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?
Document the client’s respiratory rate in 1 hr.

A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?
Improves muscle strength

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?
Check the client’s ability to use the call light.

A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?
Cloudy vision

A nurse is caring for a client who was diagnosed with hyperemesis gravidarum. Which of the following findings should the nurse anticipate?
Poor skin turgor

A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires completion of an incident report?
A nurse collects data from a client who reports severe pain and finds a dose of hydromorphone in the client’s bed.

A nurse is participating in a performance improvement process to decrease the rate of health care- associated infections within the facility. The nurse should recognize that which of the following is an appropriate performance improvement outcome indicator?
Client data indicates a decreased rate of infection.

A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?
Perform passive range-of-motion exercises.

A nurse is collecting data from a client who has hepatitis A. Which of the following findings should the nurse expect?
Abdominal pain

A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the following positions should the nurse recommend for instillation of the drops?
Supine

A nurse is orienting a newly licensed nurse to a medical-surgical unit. Which of the following actions should the nurse take to verify that the newly licensed nurse understands the procedure for measuring a client’s blood glucose level?
Have the nurse perform a return demonstration.

A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first?
A client who is exhibiting flight of ideas

A nurse in the newborn nursery is collecting data about a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?
Strike the crib surface on which the newborn is lying.

A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take?
Secure the restraint with an easy-to-release tie.

A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?
Working phase

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates the client is experiencing an allergic reaction?
Urticaria

A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?
Methylergonovine

A nurse is caring for an older adult client who has pneumonia. When reinforcing teaching about the diagnosis and age-related changes with the client’s family, which of the following alterations should the nurse include?
Increased elasticity of the thoracic cage

A nurse is collecting data from the guardian of a toddler during a well-child visit. The guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk each day. The nurse should identify that this practice places the toddler at risk for which of the following conditions?
Lactose intolerance

A nurse is caring for a school-age child who is scheduled for a bone marrow aspiration biopsy. The child asks the nurse, “Will this be painful?” Which of the following is an appropriate response by the nurse?
“There will be some pain, but I can give you medicine to make you more comfortable.”

A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client’s belongings, which of the following items should the nurse remove from the client’s suitcase?
Perfume

A nurse is assisting with a group therapy session in which a client begins to monopolize the group’s time. Which of the following interventions is appropriate?
Schedule one-on-one discussion time with the client.

A nurse is caring for a client who is 3 days postoperative following abdominal surgery and has a Penrose drain. Which of the following actions should the nurse take?
Reposition the sterile safety pin when the surgeon advances the drain.

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 in a long-term care facility is observing an assistive personnel (AP) who is performing hand hygiene. Which of the following actions by the AP requires intervention?
Holding his hands up and elbows down while washing his hands

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client’s right leg should be of the most concern to the nurse?
The client’s pedal pulse in the right foot is not palpable.

A nurse is caring for a client who is experiencing chest pain. The client states, “I am really afraid because my brother died a year ago of a heart attack.” Which of the following responses is appropriate?
“This must be a frightening experience for you.”

A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to the newborn nursery. For which of the following newborn care procedures should the nurse remind the AP to wear clean gloves?
Applying an identification bracelet

A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse expect in the affected extremity?
Dull, aching pain

A nurse is caring for a client who is receiving morphine 2 mg subcutaneously every 4 hr for pain. The medication is available in a vial containing 10 mg/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
0.2 ML

A nurse is caring for a client who is receiving prazosin. The client’s blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?
Instruct the client to stand up slowly.

A nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse?
The television set is turned to a loud volume.

A nurse in a prenatal clinic is reinforcing teaching with a client about a nonstress test. Which of the following statements should the nurse include?
“You will be asked to press a button when you feel your baby move.”

A nurse is preparing to instill an otic suspension into an adult client’s ear. Which of the following methods should the nurse plan to use?
Pull the auricle upward and backward.

A nurse is reinforcing teaching about colostomy care with a client. Which of the following client statements indicates an understanding of how to care for the colostomy?
“I will empty the colostomy bag when it is one-half full,”

A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is the best indication that the client needs PRN pain medication?
The client reports pain.

A charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse plan to delegate to an assistive personnel?
Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection

A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to receive cefaclor 30 mg/kg/day to divide equally every 8 hr. Available is cefaclor suspension 125 mg/5 mL. How many ml should the nurse administer for one dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
8

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 humanus capitis. Which of the following should the nurse include in the teaching?
Wash the bed linens in hot water.

A nurse in an inpatient mental health facility is caring for a client who has bipolar disorder and is in an acute manic episode. Which of the following activities should the nurse suggest for the client?
Take a walk with a staff member,

A nurse is reinforcing healthy eating habits for an older adult client to ensure adequate dietary intake. Which of the following is an appropriate recommendation?
Snack between meals.

A nurse in a provider’s office is collecting data from a client who was discharged from the hospital 7 days ago following treatment for deep-vein thrombosis. Which of the following findings is the nurse’s priority? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
The client takes ibuprofen daily to treat musculoskeletal pain.

A nurse is preparing to administer an IM injection to a client. To reduce the risk of a needlestick injury, the nurse should take which of the following actions?
Dispose of the used needle immediately in a puncture-proof sharps container.

A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which following results should the nurse notify the provider?
Platelet count 90,000/mm3

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine. Which of the following statements indicates understanding of the instructions?
“I need to take this medication for the rest of my life.”

A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?
Intradermal

A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?
Graham crackers

A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following?
Vitamin D

A nurse working in a long-term care facility is assisting with the plan of care for a client who has Alzheimer’s disease. The nurse notes that the client wanders the halls at night and says she is looking for the bathroom. Which of the following interventions should the nurse recommend to include in the plan of care?
Label the client’s bathroom door.

A nurse is reinforcing discharge teaching with an older adult client’s family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?
Instruct the client to bear down during rectal tube insertion.

A client who is prescribed metoprolol for hypertension tells the nurse, “I don’t want to take this medication because makes me tired all the time.” Which of the following is the appropriate response?
“Let’s talk with your doctor about other options.”

A nurse is preparing to catheterize a client’s bladder to check for residual urine. The nurse should schedule this procedure at which of the following times?
Right after the client voids

A nurse on a mental health unit is discussing client rights with a group of coworkers. Which of the following statements should the nurse include?
“A client must withdraw consent for treatment in writing if he is competent to do so.”

A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates the client might be experiencing diabetic ketoacidosis?
Anuria

A nurse is reinforcing teaching with the parent of a toddler who has difficulty falling asleep. Which of the following instructions should the nurse include?
Establish a bedtime routine.

A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication? (Select all that apply.)
PT Serum potassium INR Serum sodium BUN

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?
The infusion pump for administering contimuous feeding is turned off.

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?
Hypotension

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 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 a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
1 cm of water present in the water seal

A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?
The client takes aspirin daily.

A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?
series of four hepatitis vaccines is recommended to prevent viral hepatitis.

A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?
Elevated pulmonary artery pressure

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?
Inform the client of available community resources.

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.”

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

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?
Wear an N95 respirator.

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider’s prescription should include the

A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include?
Educating the client how to cover nose and mouth with tissues when coughing

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 hours when the client is awake.

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?
Review deep breathing and coughing exercises.

A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take?
Report to the nurse manager.

A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?
The tubing may be kinked.

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?
Measure the amount of gastric drainage every 2 hr.

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client’s BMI falls within which of the following categories?
Healthy weight

A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome?
Change in mental status

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Administer pain medication to the client.

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 planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include?
Place the infusion pump cord against the baseboards.

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

A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
Generalized edema

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?
Head compression

nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?
Pertussis

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 at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?
A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?
Rephrase sentences the client does not understand.

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?
Lean in slightly when speaking to the client.

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?
A client who had a stroke 2 days ago and needs help toileting

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

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 preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins.

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?
Eat a dry carbohydrate before getting out of bed.

A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client’s perineal area. Which of the following is a priority action by the nurse?
Check the FHR.

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.

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?
Hypertension

A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,
“My stoma will drain liquid fluid continuously.”

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 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 reviewing the medical record of a client who has 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?
Furosemide

A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI?
Urine output of 250 mL/hr

A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?
Sputum culture

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 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-Fowler’s position.

A nurse is assessing a client’s internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?
Dim the lights in the room prior to the examination.

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?
Iron

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIS). 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 cirrhosis of the liver. Which of the following actions should the nurse take?
Monitor for abdominal ascites.

A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrelipase. Which of the following should the nurse include in the teaching?
Take with meals.

A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?
Discard opened cans of formula after 24 hr.

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?
Ototoxicity

A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?
Improve joint functioning.

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 encourages the family to coordinate health care services.

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?
Monitoring the insertion site for infection

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?
Require the cient wear a dosimeter badge.

A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make?
“Hepatitis A can be spread by fecal-oral contact.”

A nurse in a mental health clinic is observing clients the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, “Why did you choose to talk to me out of this room full of kids?” Which of the following responses by the nurse is therapeutic?
“You’re curious why I am interested in you and not the others?”

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

the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of
Abdominal rigidity

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 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 opioid use disorder and is experiencing withdrawal. Which of following findings should the nurse expect?
Hyperreflexia

A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?
relieved by position change

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?
Pulse 54/min

A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation?
Sucralfate 1 g PO 1 hr ac

A nurse is evaluating the allergy profile of a client who has Graves’ disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan?
lodine

A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?
Open the client’s windows.

A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.)
witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan.” “A client who signs an informed consent form should be competent.” “The nurse should disclose the purpose of the treatment before the client signs the consent form.”

A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?
Administer the medication with a glass of orange juice.

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?
“Bring the child to the funeral service before visitors arrive.”

A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload?
Bounding pulses

A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective?
Weight loss

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 (18 in) from the light source.

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?
“I am thankful there are no serious complications from this type of surgery.”

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
Blood pressure 94/68 mm Hg

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?
An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo

A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care?
Teach the client to meditate about obsessive thoughts.

A nurse is caring for client who has schizophrenia. Which of the following findings is the nurse’s priority?
The client reports hearing voices.

A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?
Use aseptic technique and drop the medication into the conjunctival sac.

A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.)
Repeats the words of others when speaking Speaks in word salad Has a blunt affect Experiences delusions

A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider?
No bowel movement for 3 days

A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?
“Please stop this discussion.”

A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?
Determine the client’s pain level.

A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching?
Avoid foods that have high levels of oxalates.

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?
A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days

A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?
Maintain the head at a midline position.

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?
Troponin I 1.8 ng/mL

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?
0900

A client who has a diagnosis of com acenta is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take?
Prepare the client for a cesarean section.

A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating?
Justice

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 is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe?
Sertraline

A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first?
A client who has gastroenteritis and is lethargic and confused

A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client?
Participate in a 12-step program.

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 following is the priority action?
Notify the facility

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 V.

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?
Pulse oximeter

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 monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
Swollen lips

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include?
Gently massage the skin under the straps once per day.

A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?
Identify the reason for the client’s refusal.

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?
Clopidogrel

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 from the State Health Department 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 nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication this medication?
Нерatitis C

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?
Occlude the IV tubing above the injection port.

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?
Compare blood pressure in both arms every 2 hr.

A nurse enters a client’s room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report?
Client found lying on the floor near the bedside table.

A client who is having suicidal thoughts tells the nurse, “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?
“Do you have a plan to end your life?”

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (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 caring for an adolescent who is receiving treatment for heart failure. Based on the client’s chart findings, which of the following actions should the nurse plan to take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Withhold digoxin.

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is
asymmetric, with variegated coloring.

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?
Consistent contractions last 80 seconds.

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?
Pedal pulses 2+

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?
The client pockets food on one side of his mouth.

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 creating a plan 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 performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?
A dient who has a traumatic arm amputation

A nurse performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take prevent a pressure injury?
Encourage client fluid intake of 2,500 ml daily.

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 observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
Viewing the newborn’s actions to be uncooperative

A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer’s lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take?
Review the chest x-ray report.

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?
Uses others for personal gain