vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?
The
... [Show More] infant closes their eyes.
A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include?
Place the infusion pump cord against the baseboards.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene?
Offers oral fluids to the client
A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
Generalized edema
A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?
Head compression
nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?
Pertussis
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications?
Shellfish allergy
A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?
A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Rephrase sentences the client does not understand.
A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview?
Lean in slightly when speaking to the client.
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?
A client who had a stroke 2 days ago and needs help toileting
A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?
A brainstorming session with nurses
A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include?
"Try to have your baby empty your breasts with each feeding."
A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins.
A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?
Eat a dry carbohydrate before getting out of bed.
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?
Check the FHR.
A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?
Report the incident to Adult Protective Services.
A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine?
Hypertension
A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,
"My stoma will drain liquid fluid continuously."
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Indigestion
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?
Opioid intoxication
A nurse is reviewing the medical record of a client who has new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity?
Furosemide
A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI?
Urine output of 250 mL/hr
A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?
Sputum culture
A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?
Allow the infant to suck on a pacifier during feedings.
A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?
Place the client in a low-Fowler's position.
A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?
Dim the lights in the room prior to the examination.
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation?
Iron
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIS). [Show Less]