1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse
... [Show More] include in the plan of care?
2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse?
3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply.)
4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrive. Which of the following statements by the nurse is appropriate?
5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should the nurse include in the teaching?
6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse?
7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?
8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? talaga
9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate dehydration?
10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?
11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?
12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?
a. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?
14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following should the nurse include in the teaching?
15. A nurse in the emergency department is caring for a client who has a 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?
16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results with her partner. Which of the following is an appropriate response for the nurse to make?
17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury. Which of the following recommendations should the nurse include in the teaching?
18. A nurse is 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?
19. A nurse is assessing a client who is 8 hr postpartum and has been unable to void. Which of the following actions should the nurse take first?
20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin. Which of the following statements by the nurse is appropriate?
21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings indicates the client is experiencing a fat embolism?
22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching?
23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? TALAGA
24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the following statements should the nurse include in the teaching?
25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take?
26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching?
27. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide?
28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
29. A nurse is caring for four clients. Which of the following clients should the nurse care for first?
30. 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 to using lavender?
31. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching?
32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the following manifestations should the nurse expect?
33. A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse determines that cranial nerve XI is intact when the client performs which of the following actions?
34. A nurse is preparing to administer lactated Ringer’s 500 mL IV to infuse over 4 hrs. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole noumber. Use a leading zero if applicable. Do not use a trailing zero.)
35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?
36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis following surgery. Which of the following actions should the nurse take?
37. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
38. A nurse is developing a nutritional care plan for a client who has COPD with severe dyspnea. To promote intake, which of the following instructions is appropriate to include in the plan of care? TALAGA
39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? TALAGA
40. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? TALAGA
41. A nurse in an oncology clinic receives a call from the partner of a client who has pancreatic cancer. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make?
42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories of data.)
43. A nurse preceptor is working with a newly licensed nurse to care for a client who has vancomycin-resistant enterococci (VRE). Which of the following actions by the newly licensed nurse requires the nurse preceptor to intervene?
44. A nurse in a health clinic is developing written material to teach adult clients how to manage their blood pressure. Which of the following strategies should the nurse use in creating the material?
45. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
46. A nurse in a mental health facility received change-of-shift report on four clients. Which of the following clients should the nurse plan to assess first?
47. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should recognize that atrial fibrillation places the client at risk for which of the following?
48. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
49. A nurse is caring for a client who is not ambulatory. Which of the following interventions is appropriate to prevent contracture?
50. A nurse is caring for a client who has a thoracic spine injury. Which of the following actions is appropriate for the nurse to take when turning the client?
51. A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?
52. A nurse is caring for a client who is incontinent and has a stage II pressure ulcer on her coccyx. Which of the following interventions should the nurse implement?
53. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
a. R: ati Maternal newborn p60
Eclampsia is severe preeclampsia manifestations with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions.
54. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (Select all that apply)
55. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate?
56. A nurse is caring for a client who has schizoaffective disorder and tells the nurse, “I’m the prince of peace and my enemies are coming to take me to another world.” Which of the following responses should the nurse make?
57. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?
58. A charge nurse is providing information to a group of nurses on the unit about risk factor for hypoglycemia in newborns. Which of the following risk factors should the charge nurse include in the information? (Select all that apply)
59. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? [Show Less]