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RN COMPREHENSIVE PREDICTOR 2019 FORM A, B, & C -100% VERIFIED
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RN COMPREHENSIVE PREDICTOR 2019 FORM A COMPLETE SOLUTION
RN COMPREHENSIVE PREDICTOR 2019 FORM A COMPLETE SOLUTION 1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the... [Show More] following actions should the nurse take? A. (Unable to read) B. Tell the child they will feel discomfort during the catheter insertion. C. Use a mummy restraint to hold the child during the catheter insertion. D. Require the parents to leave the room during the procedure. 2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings should the nurse report? A. Thrill upon palpation. B. Absence of a bruit. C. Distended blood vessels D. Swishing sound upon auscultation. 3. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? A. “I will soak in the tub rather and showering” B. “I will wear loose clothing around my ICD” C. “I will stop using my microwave oven at home because of my ICD” D. “I can hold my cellphone on the same side of my body as the ICD” 4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? A. “Describe your feelings to me about being pregnant” B. “You should discuss your feelings about being pregnant with your provider” C. “Have you discussed these feelings with your partner?” D. “When did you start having these feelings?” 5. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client’s diet. C. Provide the client with a cold drink prior to defecation. D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.6. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? A. Administer ondansetron. B. Place the client in a warm shower. C. Apply fundal pressure during contractions. D. Assist the client to a supine position. 7. a nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? A. Below-the knee amputation B. Fractured tibia C. 95% full-thickness body burn D. 10cm (4in) laceration to the forearm 8. a nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client’s restraint every 4hr B. Document the client’s condition every 15 min C. Attach the restrain to the bed’s side rails D. Request a PRN restrain prescription for clients who are aggressive 9. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? A. Acts as an advocate for the nursing unit. B. (Unable to read) for the unit C. Priorities staff request over client needs. D. Provides routine client care and documentation. 10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. A. Serum sodium 144 mEq/ B. (Unable to read) C. Hba1c 10 % D. Random serum glucose 190 mg/dl.11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department? A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus 12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching? A. Share personal opinions to help influence the group’s values B. Measure the accomplishments of the group against a previous group C. Yield in situations of conflicts to maintain group harmony D. Use modeling to help the clients improve their interpersonal skills 13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care? A. Provide chicken with cream sauce. B. Avoid serving fish with fins and scales. C. Provide unleavened bread. D. Avoid serving foods containing lamb. 14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment A. A chest x-ray reveals increased density in all fields. B. The client reports feeling less anxious. C. Diminished breath sounds are auscultated bilaterally D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg. 15. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next. A. Monitor the client’s IV site for thrombophlebitis. B. Administer flumazenil to the client. C. Evaluate the client for further suicidal behavior. D. Initiate seizure precautions for the client.16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect? A. Hypotension B. Memory loss C. Slurred speech D. Elevated temperature 17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? A. Loose stools B. Jitteriness C. Hypertonia D. Abdominal distention 18. A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider? A. Hgb 12.5 g/dl B. Platelets 250,000/mm3 C. Hct 40% D. WBC 14,000/mm3 19. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include? A. “The proxy should make health care decisions for the client regardless of the client’s ability to do so.” B. “The proxy can make financial decisions if the need arises.” C. “The proxy can make treatment decisions if the client is under anesthesia.” D. “The proxy should manage legal issues for the client.” 20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first? A. Turn the client on their side. B. Administer an analgesic C. Administer antiemetic D. Monitor the client’s vital signs.21. A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes. 23. A 24. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which of the following client should the nurse delegate to the LPN? A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs. B. A client who sustained a concussion and has unequal pupils. C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction. D. A client who fractured his femur yesterday and is experiencing shortness of breath. 25. A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? A. Place the client upright on a donut-shaped cushion B. Teach the client to shift his weight every 15 min while sitting C. Turn and reposition the client every 3 hr while in bed D. Assess pressure points every 24 hr 25. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-management (Unable to read) a safe option for the client? A. Naloxone hydrochloride. B. Spinal anesthesia. C. Pudendal block. D. Butorphanol tartrate.26. C 27. A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?) A. The client changes the subject when future plans are mentioned. B. The client talks about being in pain constantly. C. The client sleeping over 12 hr. each day. D. The client reports giving away personal items. 28. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply) A. Varicella vaccine. B. Inactivated polio vaccine. C. Tetanus diphtheria and acellular pertussis vaccine D. Rubella vaccine. E. Inactivated influenza vaccine. 29. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure? A. Amputation B. Osteoarthritis C. Hypertension D. Primary glaucoma 30. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”.31. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? A. “I can give you information about respite care if you are interested.” B. “You should consider taking a sleeping pill before bed each night” C. “It must be difficult taking care of someone who is terminally ill” D. “You are doing a great job taking care of your mother” 31. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medications A. Methylprednisolone. B. Ondansetron. C. Guaifenesin. D. Amoxicillin. 32. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? A. “You should take folic acid to decrease the risk of transmitting infections to your baby” B. “You should consume a maximum of 300 micrograms of folic acid every day”. C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. D. “You can expect your urine to appear red-tingled while taking folic acid supplements”. 33. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority? A. Social relationship with peers. B. Plans for attending school while pregnant. C. (Unable to read) (Picked this one) Medicaid? D. Understanding of infant care. 34. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? A. Critical pathways have unlimited timeframe for completion B. (Unable to read) decrease health care costs. C. (Unable to read) critical pathway if variances (Unable to read) D. (Unable to read) are used to create the critical pathway.35. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heart rate. C. Sore throat. D. Blood pressure. 36. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel A. “The nurse is legally responsible for the actions of the AP”. B. “An AP can perform tasks outside of his range if he has been trained”. C. “An experienced AP can delegate to another AP”. D. “An RN evaluates the client needs to determine tasks to delegate” 37. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3)38. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse’s priority? A. Consult with a case manager about insurance coverage. B. Counsel caregivers about respite care options. C. Ensure that the client has a referral for physical therapy. D. Refer the client to a local stroke support group. 39. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station? A. A client who has an anxiety disorder and is experiencing moderate anxiety. B. A client who has somatic symptom disorder and reports chronic pain. C. A client who has depressive disorder and reports feeling hopeless. D. A client who has bipolar disorder and impaired social interactions. 40. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 41. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? A. Encourage the client to spend time in the day room B. Withdraw the client’s TV privileges is the does not attend group therapy C. Encourage the client to take frequent rest periods D. Place the cline in seclusion when he exhibits signs of anxiety 42. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A. A client receives his antibiotics 2hr late B. A client vomits within 20min of taking his morning medications C. A client requests his statin to be administered at 2100 D. A client asks for pain medication 1hr early43. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of the following responses should the nurse make? A. “Does the doctor know you are eating that?” B. “Why are you eating seaweed soup?” C. “Of course I will heat that up for you” D. “The hospital good is more nutritious” 44. a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? A. Leaving a nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of the client’s medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls 45. a nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? A. Establish a toileting schedule for the client B. Use clothing with buttons and sippers C. Discourage physical activity during the day D. Engage the client in activities that increase sensory stimulation 46. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 47. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client? A. “Do you understand that the voices are not real?” B. “Why do you think the voices are talking to you?” C. “Have you tried going to a private place when this occurs?” D. “What helps you ignore what you are hearing?”48. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? A. Placing a belt restraint on a school-age child who has seizures. B. Securing wrist restraints to the bed rails for an adolescent. C. Applying elbow immobilizers of an infant receiving cleft lip injury D. Keeping the side rails of a toddler’s crib elevated. 49. B 50. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following A. Inject air into the NPH insulin vial. B. (Unable to read) C. Withdraw the prescribed dose of regular insulin D. Withdraw the prescribed dose of NPH insulin 51. a Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? A. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 51. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 52. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse? A. Waits 2 minutes between suctions. B. Encourages the client to cough during suctioning. C. Apply suctioning for 15 seconds. D. Inserts the catheter without applying suction.53. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 54. A nurse is providing care for a group of clients. Which of the following client’s should the nurse identify as having the highest risk for developing a pressure injury? A. A client who has a T-tube following an open cholecystectomy. B. A client who had a knee 2 days ago following a sports injury. C. A client who has dementia and is incontinent of urine and feces D. A client who has a myocardial infarction and is receiving thrombolytic therapy. 55. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching? A. “I will place the eye drops in the center of my eye” B. “I will place pressure on the corner of my eye after using he eye drops” C. “I should expect my tears to turn a red color after using the eye drops.” D. “I should expect the eye drops to appear cloudy.” 56. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Faintness upon rising C. Swelling of the face D. Urinary frequency 57. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make? A. “I would recommend sharing your feelings with a psychologist”. B. “I can give you information about making end of life decisions”. C. “You should discuss your end life decisions with your family” D. “Everyone feels this way at first. You will start feeling better soon”.58. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? A. Keep client’s calcium gluconate at the client’s bedside B. Monitor blood pressure every 2 hr. C. (Limit or remove?) IV bag from exposure to light. D. Attach tan inline filter to the IV tubing. 59. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? A. Feelings of dread B. Heightened perceptual field C. Rapid speech D. Purposeless activity 60. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication. 61. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A. Stay in bed at least 1hr if unable to fall asleep B. Take 1 hr nap during the day C. Perform exercise prior to bed D. Eat a light snack before bedtime 62. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine.63.A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take? A. Assess the amount of drainage in the collection chamber. B. Clamp the chest tube during ambulation. C. Report continuous bubbling in the water seal chamber. D. Strip the chest tube every 4 hr. to maintain patency. 64. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN. The nurse should monitor for which of the following adverse effects? A. Productive cough. B. Urinary retention. C. Rhinitis D. Fever. 65. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? A. “Can you talk about what happens with your partner at home?” B. “Why do you think your partner’s symptoms are progressing so quickly?” C. “You should make sure your partner takes the prescribed medication.” D. “You did the right thing by bringing your partner in for treatment.” 66. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching? A. “I will put my child on a gluten-free diet”. B. “I will administer digestive enzymes with meals and snacks”. C. “Provide my child with some high fiber foods.” D. “I will give my child whole wheat toast and milk for breakfast”. 67. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr.68. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of continuous infusions should the nurse initiate? A. 0.9% normal saline. B. NPH insulin. C. Glargine insulin. D. 0.45% saline. 69. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? A. Drink 1.5L fluids each day. B. Take mineral oil at bedtime. C. Increase exercise activity D. Decrease insoluble fiber. 70. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? A. “Drink 2 liters of warm water per day”. B. “Empty your bladder every 6 weeks.”. C. “Soak in a warm bath everyday”. D. “Take an oral estrogen tablet”. 71. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 72. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? A. Consume food high in bran fiber B. Increase intake of milk products C. Sweeten foods with fructose corn syrup D. Increase foods high in gluten73. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? A. the infant 30 ml (1 oz) glucose water every 2 hr. B. Keep the infants head covered with a cap. C. Ensure that the newborn wears a diaper. D. Apply lotion to the newborn every 4 hr. 74. a nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. “(Unable to read) I feel to be in his best health care decision” B. “I will intervene if there is conflict between a client and his provider” C. “I should not advocate for a client unless he is able to ask me himself” D. “I will inform a client that his family should help make his health care decisions.” 75. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? A. Raise the side rails on both sides of the client’s bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client’s preferences for determining a reposition schedule. D. Evaluate the client’s ability to help with repositioning. 76. A 77. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? A. Weak femoral pulses B. Frequent nosebleeds C. Upper extremity hypotension D. Increased intracranial pressure\78. a nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 78. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. 79. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth80. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? A. The client’s pulse oximetry level is 96%. B. (Unable to read) C. The client develops hiccups. D. The ECG shows pacing spikes after the QRS complex. 81. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? A. Personal blogs about managing the adverse effects of diabetes medications B. Food label recommendations from the Institute of Medicine C. Diabetes medication information from the Physicians’ Desk Reference D. Food exchange lists for meal planning from the American Diabetes Association 82. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? A. “The PCA will deliver a double dose of medication when you push the button twice.” B. “You can adjust the amount of pain medication you receive by pushing on the keypad.” C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” D. “You should push the button before physical activity to allow maximum pain control.” 83. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? A. Glargine insulin. B. Regular insulin. C. NPH insulin. D. Insulin aspart. 84. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom.85. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? A. Administer a refrigerated feeding. B. Increased the amount of water use to flush the tubing. C. (Unable to read) rate of the client’s feedings. D. Instruct the client to move onto their right side. 86. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority? A. Monitor the client’s ECG B. Take the client’s vital signs. C. Administer oxygen D. Insert an IV line. 87. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? A. Provide information about stress management. B. Maintain a cool temperature in the client’s room. C. Administer epinephrine for acute episodes. D. Give glucocorticoid steroid twice per day. 88. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina? A. Hyperlipidemia. B. COPD C. Seizure disorder D. Hyponatremia. 89. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. B. Magnesium hydroxide 30 ml PO. C. Famotidine 20 mg PO. D. Loperamide 4 mg PO.90. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? A. Contact the client’s family about the incident. B. Notify the client’s provider about the incident. C. File a complaint with the facility’s ethics committee. D. Report the incident to the AP’s charge nurse. 91. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? A. Withhold all medications until after dialysis B. Rehydrate with dextrose 5% in water for orthostatic hypotension. C. Check the vascular access site for bleeding after dialysis. D. Give an antibiotic 30 min before dialysis. 92. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority? A. Develop a safety plan with the client B. (Unable) options for reporting the incident. C. Refer the client to a community support group. D. Determine if the client has any injuries. 93. A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis 94. A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea.95. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty 96. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number) __6__mL/hr 97. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? A. “This test should be performed after your baby is 24 hours old.” B. “A nurse will draw blood from your baby’s inner elbow.” C. “Your baby will be given 2 ounces of water to drink prior to the test.” D. “This test will be repeated when your baby is 2 months old.” 98. A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. “My stool will become fully formed within 3 weeks” B. “My skin will need to be cleaned with alcohol before I apply a new pouch” C. “I should avoid eating popcorn and fresh pineapple” D. “I should expect bruising around the stoma” 99. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority? A. Refer the client to a speech language pathologist. B. Monitor the client’s prealbumin levels C. Measure the client’s weight. D. Place the client on NPO status.100. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 101. A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client’s current pain level. D. Instruct the client about dietary restrictions. 102. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice. D. Warm toast with margarine. 103. A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. “I cannot be a witness for your consent to donate.” B. “Your name cannot be removed once you are listed on the organ donor list.” C. “Your desire to be an organ donor must be documented in writing.” D. “You must be at least 21 years of age to become an organ donor.” 104. A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily.107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist 109. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? A. Return unopened equipment to the supply center B. Leave the unused infusion pump in the room until discharge C. Stock the room with a 2-day supply of disposable diapers D. Being in formula as needed 108. A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3 109. A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables.110. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide? A. “Add salt to season” B. “Ice chips” C. “Rinse your mouth with an alcohol-based mouthwash” D. “Eat foods served at hot temperatures” 111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions 112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 113. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) A. Identify family needs interventions using the nursing process. B. Record information about the home visit according to agency policy. C. Contact the family to determine availability and readiness to make an appointment D. Discuss plans for future visits with the family. E. Clarify the reason for the referral with the provider’s office. E C A B D (My choice) 114. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing”115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? A. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler’s position during the feeding D. Receiving a high osmolarity formula 116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? A. Take magnesium hydroxide for indigestion B. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium 118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. First degree AV block B. Premature ventricular contraction. C. Sinus bradycardia. D. Atrial fibrillation. 119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? A. Provide the client with an instructional handout about swallowing exercises. B. Ask a speech therapist to evaluate the client’s ability to swallow. C. Discuss the manifestations of impaired swallowing with the AP. D. Listens to the client’s lung sounds. 120. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? A. Ask the client directly what he is hearing B. Encourage the client to lie down in a quiet room C. Avoid eye contact with the client D. Refer to the hallucinations as if the are real120. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? A. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease” B. “There is no need to have genetic counseling if I know that I have a family history of mental illness.” C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” D. “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.” 121. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. “The cord stump will fall off in 5 days.” B. “Contact the provider if the cord stump turns black.” C. “Clean the base of the cord with hydrogen peroxide daily.” D. “Keep the cord stump dry until it falls off.” 122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. “I have my eyes examines annually” B. “I take a calcium vitamin supplement daily” C. “I limit my intake of foods with potassium” D. “I constantly take my medication between 8 and 9 each evening” 123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? A. Stands with feet together when lifting a client up in bed. B. Raises the client’s head of bed before pulling the cline up. C. Uses a mechanical lift to move client from bed to chair. D. Places a gait belt around the client’s upper chest before assisting a client to stand. 124. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? A. “Your bladder should be full prior to me performing this test B. “If this test is positive you will be required to have a non-stress test. C. “This test will determine if there is leaking amniotic fluid” D. “I will be taking a blood sample to test for changes in your hormones levels”125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension 126. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? A. Document clinical findings. B. Contact child protective services. C. Refer the parents to a self-help group. D. Instruct the parents about methods of discipline. 127. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client’s room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetabl [Show Less]
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RN COMPREHENSIVE PREDICTOR 2019 FORM B COMPLETE SOLUTION
RN Comprehensive Predictor 2019 Form B 1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which o... [Show More] f the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. 2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days. 3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? A. Arrange for an ethics committee meeting to address the family’s concerns. B. Support the family’s decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney. 4. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client’s room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client.D. Wear a mask when changing the linens in the client’s room. 6.A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. 8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C. Determine the client’s preferences about post mortem care. D. Request a conference with the client’s family. 9.A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing.10.A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the .following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side. 11. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority? A. Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist. 12.A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. Erythrocyte sedimentation rate 75 mm/hr 13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen. 18. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client’s mouth when he is ready to eat.B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 19. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client’s room. B. Limit the client’s visitors to 30 min per day. C. Discard the client’s linens in a double bag. Discard the radioactive source in a biohazard bag 21. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea 22. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin. A. Diabetes mellitus. B. Shoulder presentation. C. Postterm with oligohydramnios. (I think Maternal Newborn Chapter 15 page 100)D.Chorioamnionitis 23. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. D. Jugular vein distention. E. Weight gain. D.Bradypnea 24. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 25. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 26. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors.27. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia. 28. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse. 29. A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April . Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.) 0119 date 30. A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching.UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 32. A nurse is preparing to administer eye drops to a school-age child. Identify the 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.) 1. Apply pressure to the lacrimal punctum. 2. Ask the child to look upward. 3. Pull the lower eyelid downward. 4. Instill the drops of medication. 5. Place the child in a sitting position. 5 2 3 4 1 33. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. 34. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. D. Contractions every 5 min that last 30 seconds.35.A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit. 36. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client’s blood type with the type and cross match specimens. B. Confirm the provider’s prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client’s identification band matches the number on the blood unit. 37. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. “I have been experiencing more tremors in my left arm than before” B. “I noticed that I am having a harder time holding on to my toothbrush” C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” D. “Sometimes, I feel I am making a chewing motion when I’m not eating” 38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate.D. Increased calcium. 39. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. “Did the doctor discuss with you that there was a change in this medication?” B. “I recommend that you take this medication as prescribed” C. “Do you know why this medication is being prescribed to you?” D. “I will call the pharmacist now to check on this medication” 40 A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 41. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? A. Herpes simplex. B. Human papillomavirus C. Candidiasis D. Chlamydia43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 44. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 45. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. Children who have varicella are contagious until vesicles are crusted. B. Children who have varicella should receive the herpes zoster vaccination. C. Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption. 46.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication.D. Administer the medication. 47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicine D. Codeine. 48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. Playing with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 50. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. Broiled skinless chicken breast with brown rice.D. Warm toast with margarine. 51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 54. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics. 55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use.C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 56. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area. 66. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. “Staff will apply identification band after first bath” B. “I will not publish public announcement about my baby’s birth” C. “I can remove my baby’s identification band as long as she is in my room” D. “I can leave my baby in my room while I walk in the hallway” 57. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? A. “Morphine 3 mg SQ every 4 hr. PRN for pain.” B. “Morphine 3 mg Subcutaneous (Unable to read) C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” D. “Morphine 3 mg SC q 4 hr. PRN for pain.” 58. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report. 59. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C. “Dehydration associated gastroesophageal reflux” D. “Dehydration is caused by a decreased hemoglobin and hematocrit” 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. Answer might be lower platelets. D. (Unable to read) 61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate the clients’ understanding at regular intervals. 62 C 63 A64. C 65. D 66.CD. . 67.A . 68.B 69.A 70.C71.D 72.C 73.D 74.C75.A 76.C 77.C 78.B 79. C80. D 81. A82. B 83. A 84. A 85. A 86. C87. A 88. C 89. D 90. C 91. A92. A 93. A 94. A 95. C96. C 97. D 98. D 99. D 100. D101. A 102. B 103. B 104. D105. A 106. A 107. D 108. B 109. C 110. B111. D 112. C 113. B 114. C 115. A116. D 117. B 118. D 119. D120. A 121. C 122. A 123. A124. C 125. D 126. D 127. Intradermal Injection areas A. Buttocks.B. Upper back. C. Hamstring area. 128.A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) a. Impulse control difficulty b. Left hemiplegia c. Loss of depth perception d. Aphasia e. Lack of situational awareness 128.A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? f. Teach the client to scan the right to see objects on the right side of her body. g. Place the bedside table on the right side of the bed. h. Orient the client to the food on her plate using the clock method. i. Place the wheelchair on the client’s left side. 129.A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) j. Have suction equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaffected side of the client’s mouth. m. Assign an assistive personnel to feed the client slowly. n. Teach the client to swallow with her neck flexed. 130.A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? (Select all that apply.) o. Speak to the client at a slower rate. p. Assist the client to use flash cards with pictures. q. Speak to the client in a loud voice. r. Complete sentences that the client cannot finish. s. Give instructions one step at a time. 131.A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? t. Impulse control difficultyu. Poor judgement v. Inability to recognize familiar objects w. Loss of depth perception 132.A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table. b. Explain the procedure. c. Obtain ABG’s. d. Administer benzocaine spray. 133.A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? e. Respiratory acidosis f. Respiratory alkalosis g. Metabolic acidosis h. Metabolic alkalosis 134.A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider? i. Blood-tinged sputum j. Dry, nonproductive cough k. Sore throat l. Bronchospasms 135.A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room? (Select all that apply.) m. Oxygen equipment n. Incentive spirometer o. Pulse oximeter p. Sterile dressing q. Suture removal kit 136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) r. Dyspnea s. Localized bloody drainage on the dressing t. Fever u. Hypotension v. Report of pain at the puncture site 137.A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing138.A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? f. Obtain a chest x-ray g. Apply sterile gauze to the insertion site. h. Place tape around the insertion site. i. Assess respiratory status. 139.A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) j. Continuous bubbling in the water seal chamber k. Gentle constant bubbling in the suction control chamber l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration m. Exposed sutures without dressing n. Drainage system upright at chest level 140.A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? o. Lie on it left side. p. Use the incentive spirometer. q. Cough at regular intervals. r. Perform the Valsalva maneuver. 141.A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) s. Encourage the client to cough every 2 hours. t. Check the continuous bubbling in the suction chamber. u. Strip the drainage tubing every 4 hours. v. Clamp the tube once a day. w. Obtain a chest x-ray. 142.A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and understanding of PSV? a. “It keeps the alveoli open and prevents atelectasis.” b. “It allows preset pressure delivered during spontaneous ventilation.” c. “It guarantees minimal minute ventilator.” d. “It delivers a preset ventilatory rate and tidal volume to the client.” 143.A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) e. Confusion f. Pale skin g. Bradycardia h. Hypotension i. Elevation blood pressure. 144.A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? j. Apply a vest restraint if self-extubation is attempted. k. Monitor ventilator settings ever 8 hours. l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hours.145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? n. Nonrebreather mask o. Venturi mask p. Nasal cannula q. Simple face mask 146.A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.) r. Assist-control s. Synchronized intermittent mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation v. Independent lung ventilation 146.A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postoperative and received local anesthesia. e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis 148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority? g. Obtain baseline vital signs and oxygen saturation. h. Obtain a sputum culture. i. Obtain a complete history from the client. j. Provide a pneumococcal vaccine. 149.A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. k. Administer antibiotics. (3) l. Administer oxygen therapy. (1) m. Perform a sputum culture. (2) n. Administer an antipyretic medication to promote client comfort. (4) 150.A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? o. Percussion of posterior lobes of lungs p. Auscultation of the trachea q. Inspection of the conjunctiva r. Palpation of the orbital areas 151.A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? s. “I should wash my hands after blowing my nose to prevent spreading the virus.” t. “I need to avoid drinking fluids if I develop symptoms.” u. “I need a flu shot every 2 years because of the different flu strains.”v. “I should cover my mouth with my hand when I sneeze.” 152.A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) a. SaO2 95% b. Wheezing c. Retraction of sternal muscles d. Pink mucous membranes e. Premature ventricular complexes (PVC’s) 153.A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? f. Antibiotic g. Beta-blocker h. Antiviral i. Beta2 agonist 154.A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? j. “I will decrease my fluid intake while taking this medication.” k. “I will expected to have black, tarry stools.” l. “I will take my medication with meals.” m. “I will monitor for weight loss while on this medication.” 155.A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? n. Gender o. Environmental allergies p. Alcohol use q. Race 156.A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? r. “This medication can decrease my immune response.” s. “I take this medication to prevent asthma attacks.” t. “I need to take this medication with food.” u. “This medication has a slow onset to treat my symptoms.” 157.A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates and understanding of the teaching? a. “This medication can increase my blood sugar levels.” b. “This medication can decrease my immune response.” c. “I can have an increase in my heart rate while taking this medication.” d. “I can have mouth sores while taking this medication.” 158.A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) a. Hypokalemia b. Tachycardia c. Fluid retention d. Nausea e. Black, tarry stools159.A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? a. “There are portable oxygen delivery systems that you can take with you.” b. “When you go out, you can remove the oxygen and then reapply it when you get home.” c. “You probably will not be able to go out at much as you used to.” d. “Home health services will come to see you so you will not need to get out.” 160.A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. “I will place the adapter on my finger to read my blood oxygen saturation level.” b. “I will lie on my back with my knees bent.” c. “I will rest my hand over my abdomen to create resistance.” d. “I will take in a deep breath and hold it before exhaling.” 161.A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. Take quick breaths upon inhalation. b. Place you hand over your stomach. c. Take a deep breath in through your nose. d. Puff your cheeks upon exhalation. 162.A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.) a. “I can substitute one medication for another if I run out because that all fight infection.” b. “I will wash my hands each time I cough.” c. “I will wear a mask when I am in a public area.” d. “I am glad I don’t have to have any more sputum specimens.” e. “I don’t need to worry where I go once I start taking my medications.” 163.A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. “You will need to continue to take the multi-medication regimen for 4 months.” b. “You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.” c. “You will need to remain hospitalized for treatment.” d. “You will need to wear a mask at all times.” 164.A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. “Your urine can turn a dark orange.” b. “Watch for a change in the sclera of your eyes.” c. “Watch for any changes in vision.” d. “Take vitamin B6 daily.”165.A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. “You might notice yellowing of your skin.” b. “You might experience pain in your joints.” c. “You might notice tingling of your hands.” d. “You might experience loss of appetite.” 166.A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum 167.A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation 168.A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.) f. Bradypnea g. Pleural friction rub h. Hypertension i. Petechiae j. Tachycardia 169.A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? k. Notify the provider. l. Administer heparin via IV infusion. m. Administer oxygen therapy. n. Obtain a spiral CT scan. 170.A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? o. “I am allergic to morphine.” p. “I take antacids several times a day.” q. “I had a blood clot in my leg several years ago.” r. “It hurts to take a deep breath.”171.A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count 172.A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) a. Tachypnea b. Deviation of the trachea c. Bradycardia d. Decreased use of accessory muscles e. Pleuritic pain 173.A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? a. Assess the client’s pain. b. Obtain a large-bore IV needle for decompression. c. Administer lorazepam. d. Prepare for chest tube insertion. 174.A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? a. “Notify the provider if you experience weakness.” b. “You should be able to return to work in 1 week.” c. “You need to wear a mask when in crowded areas.” d. “Notify your provider if you experience a productive cough.” 175.A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) a. Bradycardia b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxic chest movement 176.A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first?a. Obtain a chest ex-ray. b. Prepare for chest tube insertion. c. Administer oxygen via high-flow mask. d. Initiate IV access. 177.A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? e. “This medication is given to treat infection.” f. “This medication is given to facilitate ventilation.” g. “This medication is given to decrease inflammation.” h. “This medication is given to reduce anxiety.” 177.A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) a. A client who experienced a near-drowning incident b. A client following coronary artery bypass graft surgery c. A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia e. A client who experienced a drug overdose 178.A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) a. Administer antibiotics. b. Provide supplemental oxygen. c. Administer antiviral medications. d. Administer bronchodilators. e. Maintain ventilatory support. 179.A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) a. Fentanyl b. Furosemide c. Midazolam d. Famotidine e. Dexamethasone 180.A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? a. “Air should be instilled into the monitoring system prior to the procedure.” b. “The client should be positioned on the left side during the procedure.” c. “The transducer should be level with the second intercostal spaced after the line is placed.” d. “A chest x-ray is needed to verify placement after the procedure.” [Show Less]
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RN COMPREHENSIVE PREDICTOR 2019 FORM C COMPLETE SOLUTION
ATI COMPREHENSIVE C 1. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription ... [Show More] for restraints. Which of the following should the actions the nurse take? A. Request a renewal of the prescription every 8 hr. B. Check the client’s peripheral pulse rate every 30 min C. Obtain a prescription for restraint within 4 hr. D. Document the client’s condition every 15 minutes 2. A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) b. Give cromolyn nebulizer solution every 6 hr (for asthma) c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has sinus arrhythmia and is receiving cardiac monitoring b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8% c. A client who has epidural analgesia and weakness in the lower extremities d. A client who has a hip fracture and a new onset of tachypnea 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) b. Wear gloves to apply the patch to the client’s skin c. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together) 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr (can wait) c. A client who has 100 mL fluid remaining in his IV bag (can wait) d. A client who received a pain medication 30 min ago for postoperative pain 6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. A history of gastroesophageal reflux disease b. Receiving a high osmolarity formula c. Sitting in a high-Fowler’s position during the feeding d. A residual of 65 mL 1hr postprandial 7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum glucose level- increased b. Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased . 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. 9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Individual Assessment for Violence 10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level 11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime 12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the homed. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?” b. “What high school did you graduate from c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” 14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% 15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy 16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom 18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubinb. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. “I will let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.” d. “I will let the client know that an interpreter is unavailable during the night shift.” 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal 22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured left tibia and pallor in the affected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin 23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. Dry mouth→ anticholinergic effects c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to t 24. A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? P . 177 ch 26 a. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths b. The cord stump will fall off in 5 days- about 10 - 14 days c. Contact the provider if the cord stump turns black d. Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry.25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? a. White flour tortillas b. Potato pancakes c. Wheat crackers d. Canned barley soup 26. A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech d. Hypochondriasis ( anxiety disorder) 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the clients legs b. Place a towel roll under the clients neck c. Apply an orthotic to the clients foot d. Position a pillow under the client's knees 28. A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution 29. A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below the knee amputation → ESI Level 1 b. 10cm (4 in) laceration → ESI Level 4 c. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then level 1. d. 95% full thickness body burn → 30. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED a. Hgb 12.8 g/dl - 12- 16 b. Potassium 4.2 meq/l 3.5 - 5.0 meq c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl (normal: 16-40) c. Serum creatinine 0.8 mg/dld. Calcium 9.5 mg/dl 32. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN? a. A client who is postoperative following a bowel resection with an NGT set to continuous suction b. A client who has fractured a femur yesterday and is expecting SOB c. A client who sustained a concussion and has unequal pupils d. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs 33. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? p . 88 ch 13 maternity a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 34. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 35. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 36. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics.37. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. Initiate seizure precautions 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. a. Document the client's conditions every 15 minutes b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 ch 75 CONFIRMED a. Providing pain management b. Offering emotional support c. Preventing infection d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. B. Let's talk about your mom’s cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left.E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone ! 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have the right to decide who receives information - b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3% 46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage ( massage if fundus is boggy) b. Pour water from a squeeze bottle over the client’s perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client’s perineal area.( warm) 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance.48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? a. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) b. Place the client upright on a donut-shaped cushion c. Assess pressure points every 24 hr.- must assess d. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress d. We should establish our roles in the initial session. 50. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon ????? 51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) 52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. Heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses 55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagiac. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medicationb. Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputeed. Apply a transdermal nicotine patch- *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss c. Urinary retention- d. Hypertension- orthostatic hypotension it will cause instead 62. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension c. Fibromyalgia d. Fibrocystic breast condition 63. A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure 64. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. “You should not have this procedure if you are allergic to iodine.” b. “You should not have this procedure if you have a tattoo.” c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 65. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 66. A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacementb. Start a 24-hr urine collection- not the priority c. Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's disease d. Encourage ambulation- we want to promote rest to decrease 02 consumption 67. A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? B a. B. C and D not shown 68. A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? P. 249 med surg pdf a. Check the client’s vital signs from the previous shift prior to the initiation of the transfusionassess prior to infusion then be with them for first 15 - 30 minutes. b. Set the IV infusion pump to administer the blood over 6 hr c. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion- d. Administer the blood via a 21-gauge IV needle 69. A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker Rationale: 70. A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. “I try to respond to the baby quickly .” b. “I think the baby should be sleeping through the night by now. c. “I have several friends who come by to help out with the baby.” d. “I want to meet other parents to see if they are going through the same thing.”71. A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL d. Sunken fontanels and dry mucous membranes 72. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information? Request a female translator interpreter through the facility a. Ask a student nurse who speaks the same language to translate b. Have the child translate c. Allow the clients partner to translate 73. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ? A. Folate level B. INR level C. Vitamin b12 level D. Creatinine level 74. A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device 75. A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client’s ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls b. Fundus 2 fingerbreadths above the umbilicus( needs to be below or at the umbilicus) c. Uterine atony( fundus not firm which means possible hemorrhage) d. Fundus firm and to the right of the abdominal midline( fundus not midline, bladder may cause shifting if patient not voiding properly) 76. A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ? a. Polyuria- oliguriab. Hypotension- hypertension c. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine d. Weight loss - weight gain 77. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ? p. 50 ch 7 pharm pdf SSRI for social anxiety , PTSD, A. Excessive sweating B. Increased urinary frequency C. Dry cough D. Metallic taste in mouth 78. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? a. your baby will be given 2 ounces of water to drink prior to the test b. this test will be repeated when your baby is 2 months old c. a nurse will draw blood from your baby’s inner elbow d. this test should be performed after you baby is 24 hours old 79. a nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. perform the procedure prior to meals : AVOID Before or AFTER meals b. perform the procedure twice a day c. administer a bronchodilator after the procedured. hold hand flat to perform percussions on the child- 80. a nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. placing a yellow bracelet on a client who is at risk for falls→ correct approach; yellow bracelet indicates fall risk b. administering potassium via IV bolus c. documenting communication with a provider in the progress notes of the client’s medical record d. leaving a nasogastric tube clamped after administering oral medication → 81. A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness.R: p147 ati funds Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth. 82. A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrelipase b. Complete oral hygiene c. Eat a meal d. Use an albuterol inhaler 83. A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? P . 164 ch 27 medsurge a. Monitor the dorsalis pedis pulse every 15 minutes → circulation b. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usally are up to 4 hours. c. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure , and npo b4 the procedure is uP to 8 hours. d. Place the client in Fowler’s position- supine they must be 84. A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take? a. Offer high-calorie, high protein snacks to the client b. Recommend the family provide the client privacy during meals c. Weigh the client once each day d. Encourage the client to eat foods selected by the dietitian 85. A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ? a. Non maleficence b. Veracity c. Autonomyd. Justice R: p47 ati leadership Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client’s own best interest 86. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ? A. Check the mouth for smooth and smoky breath - airway obstruction via foreign body B. Calculate the fluid replacement based on vital signs and urinary output C. Determine the location and depth of burns D. Administer antibiotics to prevent sepsis. 87. A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ? a. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow b. Hyperkalemiac. Hypercalcemia d. hypoglycemia 88. a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) _____140??(not sure)_______ pounds 1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs 165 lbs-25 lbs=140 lbs or 63.6 kg (64 kg) 89. a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will change my baby’s diaper at least every 4 hours b. I will apply an ice pack to my baby’s penis twice daily to decrease swelling c. I will wash the penis with soap and warm water until the circumcision has healed d. I will apply topical lidocaine following each diaper change Teach the parents to keep the area clean. 90. a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take? a. encourage the client to increase fluid intake b. initiate a consultation with a speech→ language pathologist; swallow evalc. instruct the client that this is due to increased salivary flow that occurs with aging d. recommend an antitussive 30 minutes prior to each meal R: p56 AMS Refer to speech language therapist for dysarthria and dysphagia. 91. A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control? A. Postprandial blood glucose 190 mg/dl B. Fasting blood glucose 60 mg/dl C. HbA1c 6.5% D. Hct 42% 92. A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication? A. BUN B. Blood pressure C. Respiratory rate D. aPTT 93. A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention? A. Encouraging the client to use jet therapy on her lower back for 1 hr B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen C. Using effleurage on a client’s lower abdomen D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30 min 94. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Review the skill level of and qualifications of each AP 1 B. Communicate appropriate tasks to the APs with specific expectations 2 C. Monitor progress of task completion with each AP 3 D. Evaluate the APs’ performance of each task 4 95. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. “I should take antibiotics when I have a virus.” B. “I should wash my hands for 10 seconds with hot water after working in the garden.” C. “I can clean my cat’s litter box during my pregnancy.” D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 96. A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take? A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site. C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. 97. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy 98. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? A. Sensation of skin warmth B. Headache C. Increased salivation D. Numbness and tingling of the extremities 99. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 100. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums 101. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 D. Xerostomia 102. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus103. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming” B. “The child usually has an aura prior to onset” C. This type of seizure last 30-60 sec” D. “This type of seizure has a gradual onset” 104. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use B. Tape stockinet over monitoring device and cords C. Schedule the client as the last surgery of the day D. Remove poopsocks from the IV 105. A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication. A Dumping syndrome B Ketoacidosis C Hepatotoxicity D Thyroid storm 106. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client E. Close the door to the client's room 107. A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem 108. A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one B. Move your son to a toddler bed when the baby arrives C. Tell your son to kiss the baby D. Teach your son to change the baby diapers - not the answer109. A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probioticsC. New prescription for an iron supplement D. Intolerance to lactose 110. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse 111. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Measure the client’s urine output every hour. - monitor for toxicity. b. Restrict the client’s total fluid intake to 250ml/hr. c. Monitor the FHR via Doppler every 30 min d. Give the client protamine if sign of magnesium sulfate toxicity occur. . 112. A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? a. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation 113. A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. b. Request non gas forming foods from the dietary department c. Limit the client’s food consumption between meals. d. Arrange for a low protein diet. HIGH PROTEIN. 114. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department? a. Candidiasis b. Herpes simplex virus c. Human papillomavirus d. Chlamydia115. A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection . 116. A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. -Avoid vigorous activities. b. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds. c. I can resume activities, such as sewing. d. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level. 117. A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min [Show Less]
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