1. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the
... [Show More] nurse include in the teaching?
2. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect?
3. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?
4. A nurse is collecting data from a client and notices several skin lesion. Which of the following findings should the nurse report as possible melanoma?
5. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching?
6. A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure?
7. A nurse is reinforcing glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?
8. A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client’s manifestations indicate which of the following complications of IV therapy?
9. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching?
10. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take?
11. A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include?
12. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?
13. A nurse is assisting with the care of a client who has a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications (Select all that apply?)
14. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?
15. A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the understanding of the teaching?
16. A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?
17. A nurse is preparingto administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
18. A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?
19. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority?
20. A nurse isreinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?
21. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?
22. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?
23. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?
24. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findingsshould indicates to the nurse that the client might have a fecal impaction?
25. A nurse is providing discharge teaching for the family of a client who has Parkinson’s disease. Which of the following information should the nurse include in the teaching?
26. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that client is adhering to the nurse’s instructions?
27. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?
28. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections in a surgical wound. Which of the following information should the nurse plan to share with visitors?
29. A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals?
30. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider?
31. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?
32. A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend?
33. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse reports to the provider?
34. A nurse is caring for a client who is 13 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?
35. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication?
36. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?
37. A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?
38. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?
39. A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal?
40. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?
41. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcome from the medication should the nurse expect?
42. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?
43. A nurse is caring for a client who is 24 hr. postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications?
44. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?
45. A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?
46. A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?
47. A nurse is preparing to move a client’s NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration?
48. A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia?
49. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicate an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.)
50. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
51. A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first?
52. A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan?
53. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?
54. A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t think i can go on any longer.” Which of the following responses should the nurse make?
55. A nurse is collecting data from a 55-year old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?
56. A nurse in an oncology clinic is reinforcing teaching is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which for the following information should the nurse include in the teaching?
57. A nurse i performing ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer)
58. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?
59. A nurse is caring for an older adult client who has reddened area over the sacrum. Which of the following actions should the nurse take?
60. A nurse is caring for a client who is in Buck’s traction. Which of the following interventions should the nurse perform to reduce skin breakdown?
61. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precaustions. Which of the following actions should the nurse take?
62. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication?
63. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?
64. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?
65. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep?
66. A nurse is caring for a client who has an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?
67. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first?
68. A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?
69. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.)
70. A nurse is reinforcing teaching with a client a client who has gonorrhea. Which for the following information should the nurse include?
71. A nurse is assisting in the plan of care regarding bowel retraining for a client who has cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?
72. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr. ago. Which of the following interventions should the nurse identify as the priority?
73. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?
74. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
75. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
76. A nurse is participating in a health fair for older adult clients. Which for the following immunizations should the nurse recommend for this age group?
77. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?
78. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?
79. A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?
80. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?
81. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in order of performance. Use all the steps.)
Notify the charge nurse Check the IV site
Stop the infusion. Stop the infusion.
Elevate the affected arm. Withdraw the IV catheter.
Withdraw the IV catheter. Elevate the affected arm.
Check the IV site. Notify the charge nurse
82. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?
83. A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?
84. A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?
85. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first?
86. Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, “I’m glad they took my blood because I’m really hungry. All I’ve had since midnight is water and some juice.” Which of the following actions should the nurse take?
87. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should he nurse include?
88. A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
Exhibit 1
History and Physical
History of type 2 diabetes mellitus and
Allergies:
1) Penicillin reaction severe
2) Aspirin
3) Heparin Exhibit 2
Nurses’ Note
0730 Vital signs
Temperature 38° C (100.4° F)
Heart rate 72/min and regular
Respiratory rate 16/min
Blood pressure 128/78 mm Hg
Pain rating 6/10 Exhibit 3
Diagnostic results
Capillary glucose 102 mg/dL
89. A nurse is caring for a client who is postoperative and is receiving an IV infusion of cefzolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? [Show Less]