1. A nurse is performing tracheostomy care for a client who is postop following a laryngectomy. Which of the following actions take when suctioning the
... [Show More] client’s airway?
2. A nurse is preparing to administer a long acting insulin to a client who has DM. Which of the following actions should the nurse take first?
3. A nurse is caring for an older adult client in the PACU following gen anesthesia. Which of the following should the nurse report to the provider?
4. A nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include?
5. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff’s acceptance of this change, which of the following actions should the nurse manager take first?
6. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?
7. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?
8. A nurse who is working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury?
9. A nurse is teaching about TPN and IV lipid emulsion with a client who has an extensive burn injury. Which of the following information should the nurse include?
10. A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as an indication of fluid volume deficit?
11. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
12. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?
13. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis?
14. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching?
15. A nurse is caring for four clients at the beginning of a shift. After receiving change of shift report, which of the following clients should the nurse attend to first?
16. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?
17. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?
18. A nurse is planning care for a client who is receiving hemodialysis via an established AV fistula in the right arm. Which of the following interventions should the nurse include in the client’s plan of care?
19. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?
20. A nurse is assessing a client who has OSA. For which of the following complications should the nurse monitor?
21. A nurse in an ED is assessing a client who reports taking MDMA. Which of the following should the nurse expect?
22. A nurse is caring for a client who has a terminal illness and requests no lifesaving measure if a cardiac arrests occurs. Which of the following statements should the nurse make?
23. A nurse is administering cyclophosphamide orally to a school-aged child who has neuroblastoma. Which of the following actions should nurse take when administering this medication?
24. A nurse is reviewing the UA report of a client who has glomerulonephritis. Which of the following findings should the nurse expect?
25. A nurse is providing colostomy care for a client using a two piece pouching system. Which of the following actions should the nurse take?
26. A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube?
27. A night shift nurse is giving change of shift report to the day shift nurse who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?
28. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following food should the nurse include in the teaching?
29. An RN is planning care for a group of clients and is working with a LPN and AP. Which of the following tasks should the RN delegate to the LPN?
30. A nurse is caring for a newborn who has HSV. Which of the n=following isolation precautions should the nurse initiate?
31. A nurse is performing gastric lavage for a client who has GI bleeding and an NG tube in place. Which of the following actions should the nurse take?
32. A nurse is providing discharge instructions to a client following total hip arthroplasty. Which of the following instructions should the nurse include?
33. A nurse is reviewing lab findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following lab values indication cellular injury of myocardial tissue?
34. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client’s partner should the nurse identify as the priority?
35. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client’s safety, which of the following actions should the nurse take first?
36. An AP and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene?
37. a community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?
38. A nurse is caring for a client who has MRSA in an abd wound. Which of the following precautions should the nurse implement?
39. A nurse is teaching a client about foods high in vitamin A. which of the following foods should the nurse recommend as having the highest amount of vitamin A?
40. a nurse is caring for a client who has a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?
41. A nurse is conducting visual acuity testing using the Snellen letter chart for a school aged child who has eyeglasses. Which of the following instruction s should the nurse give to the child?
42. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?
43. A nurse is assessing a client who raynaud’s disease. Which of the following findings should the nurse expect?
44. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?
45. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?
46. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the of the following techniques should the nurse use to maintain surgical aseptic technique?
47. A home health nurse is assessing a 2 week old newborn who has a birth weight of 3.64 kg and is being breastfed. Which of the following findings indicates effective breastfeeding?
48. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which clients as having a nationally notifiable infectious condition? [Show Less]