A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? Correct Ans ~ Assist with
... [Show More] deep breathing and coughing
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? Correct Ans ~ "I told my doctor that I would like to start a support group for other women who are sick in my community"
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Correct Ans ~ Monitor the client's mouth every 8 hr
A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? Correct Ans ~ C
The nurse should assess the infant's abdomen for distention and visible peristalsis, which are manifestations of HD
A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following clients is using dissociation as a defense mechanism? Correct Ans ~ A client who was abused as a child describes the abuse as if it happened to someone else
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? Correct Ans ~ irritability
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? Correct Ans ~ A client who channels their energy into a new hobby following the loss of their job
A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? Correct Ans ~ "We can expect the hospice nurse to provide support for us after our mother's death"
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take? Correct Ans ~ Assign the client to a private room with negative air pressure
A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? Correct Ans ~ "You will need to fast the night before the test"
A nurse on a pediatric unit has received change of shift report for four children. Which of the following children should the nurse assess first? Correct Ans ~ A 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
A nurse in a community center is providing an education session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Correct Ans ~ Abdominal bloating
A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? Correct Ans ~ Check the client's oxygen saturation level
A nurse is working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? Correct Ans ~ A middle adult client who has unstable vital signs
A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? Correct Ans ~ Use a three-point gait
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? Correct Ans ~ Radial vein of the inner arm
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP? Correct Ans ~ Perform gastrostomy feedings through a client's established gastrostomy tube
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? Correct Ans ~ Use a protective cover on the scale when weighing the infant
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? Correct Ans ~ aPTT
A nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? Correct Ans ~ Time the medication was given
A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? Correct Ans ~ "I will make sure my child receives a yearly influenza immunization"
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? Correct Ans ~ Apply a cold pack to the client's ankle for 30 min every hour
A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? Correct Ans ~ Blurred vision
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? Correct Ans ~ "You have the right to change your mind about the procedure at any time"
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? Correct Ans ~ 18 g
A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? Correct Ans ~ Use the ventrogluteal site
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? Correct Ans ~ Wear clothing made with cotton fabrics while oxygen is in use
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? Correct Ans ~ "I will not allow anyone to smoke near my baby"
A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer? Correct Ans ~ Oxytocin
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? Correct Ans ~ Make a referral for social services
A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first? Correct Ans ~ Change the position of the client
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Correct Ans ~ Support the client's left arm on a pillow while sitting
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions? Correct Ans ~ Instruct the client to avoid coughing during the procedure
A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicated an understanding of isolation precautions? Correct Ans ~ "A client who requires airborne precautions should be placed in a negative pressure airflow room"
A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? Correct Ans ~ Broccoli
Yogurt
Cream cheese
Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and cream cheese do not contain tyramine.
A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect? Correct Ans ~ Acute confusion
An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia.
A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? Correct Ans ~ Use a reward system to modify the child's behavior
A nurse is preparing to administer lactated ringer's 1,500 mL IV to infuse at 50 mL/hr. 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? Correct Ans ~ 13 gtt/min
A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? Correct Ans ~ Cervical laceration
A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? Correct Ans ~ pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35 to 7.45. A pH level less than 7.35 indicated acidosis. For a client who has COPD a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45, indicating respiratory acidosis.
A nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? SATA Correct Ans ~ "Shake the medication bottle well before each dose is given
"Store the medication in the refrigerator"
"Report diarrhea to the provider immediately"
A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? Correct Ans ~ Instruct the client to void
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Correct Ans ~ Have the client wear a surgical mask while being transported outside the room
A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take? Correct Ans ~ Instruct the client to elevate the affected extremity when sitting
The nurse should instruct the client to elevate the affected extremity to reduce edema and facilitate venous return
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? Correct Ans ~ Occlusive dressing on the insertion site
Occlusive dressing on the insertion site prevents air from leaking and is an expected finding
A nurse on an impatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? Correct Ans ~ The client is pacing around the chair in which their partner is sitting
Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.
A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an AP? Correct Ans ~ Arrange the lunch tray for a client who has a hip fracture
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? Correct Ans ~ Decreased hallucinations
Chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia
A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. Correct Ans ~ Inspection
Auscultation
Percussion
Palpitation
A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? Correct Ans ~ Determine the client's reading skills
A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? Correct Ans ~ Increase the client's dietary iron intake
Clients who have rheumatoid arthritis require food high in protein, vitamins, and iron to promote tissue repair.
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? Correct Ans ~ Explore the client's reasons for refusing the treatment
A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? Correct Ans ~ An older adult client who is anxious and attempting to pull out an IV line
A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Correct Ans ~ Fiber
To reduce diarrhea and inflammation
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? Correct Ans ~ Delegate non-nursing tasks to ancillary staff
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? Correct Ans ~ Nasal flaring
The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? Correct Ans ~ Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration
A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? Correct Ans ~ A client who has cellulitis and is receiving oral antibiotics every 8 hr
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse in unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? Correct Ans ~ Proceed with provision of medical care [Show Less]