• A nurse assesses an older adult’s skin. Which findings require immediate referral?
(Select all that apply. Lesion with various colors Asymmetric
... [Show More] 6-mm dark lesion on forehead
• A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy.
What action by the nurse is best? Coordinate continuation of the therapy.
• A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?
Pain
• A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? Auscultate lung sounds.
• A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours
for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse take? Assess the IV site at least every 2 hours for thrombophlebitis.
• A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action
should the nurse take first? Assess the right leg for pulses, skin color, and temperature
• A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from
converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
• A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest.
• A nurse is assessing clients on a medical-surgical unit. Which adult client should the
nurse identify as being at greatest risk for insensible water loss? Anxious client who has tachypnea
• A nurse plans care for a client who has a wound that is not healing. Which focused
assessments should the nurse complete to develop the client’s plan of care? (Select all that apply.) Height, Alcohol use, Prealbumin laboratory results
• A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse
reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? There are no distant metastases noted in the report.
• A nurse is working with a community group promoting healthy aging. What
recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed
• The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?Severe osteoporosis
• After teaching a client about advance directives, a nurse assesses the client’s
understanding. Which statement indicates the client correctly understands the teaching?
"An advance directive will specify what I want done when I can no longer make decisions about health care."
• The nurse working in the rheumatology clinic is seeing clients with rheumatoid
arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren’s syndrome? Visual acuity
• The nurse is presenting information to a community group on safer sex practices. The nurse
should teach that which sexual practice is the riskiest?Anal intercourse
• A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below Punch skin biopsy
• After educating a caregiver of a home care client, a nurse assesses the caregiver’s
understanding. Which statement indicates that the caregiver needs additional education?" If his tailbone is red and tender in the morning, I will massage it with baby oil "
• A nurse is talking with a client about a negative enzyme-linked immunosorbent assay
(ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?Assess the client's sexual activity and patterns.
• A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which
question should the nurse ask prior to starting this therapy?"Which method of contraception are you using?"
• A nurse on the medical-surgical unit has received a hand-off report. Which client
should the nurse see first? Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
• A nurse identifies clinical practice problems on a cardiac unit. Which question is a
background question? "How are a client's vital signs affected by anxiety?
• After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client’s understanding. Which statement indicates the client has a good understanding of this condition? "I can use powder to keep this area dry."
• After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client’s
understanding. Which statement indicates the client correctly understands the teaching?" I'll cleanse the are prior to applying antibiotic cream "
• A client is in the preoperative holding area prior to surgery. The nurse notes that the client
has allergies to avocados and strawberries. What action by the nurse is best? Ensure the information is relayed to the surgical team.
• A nurse is assessing a client for acute rejection of a kidney transplant. What
assessment finding requires the most rapid communication with the provider?
Creatinine of 3.9 mg/dL
• A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? Irregular blue mole with white specks on the lower leg
• The nurse is caring for a client with an acute burn injury. Which action should the nurse take
to prevent infection by autocontamination?Change gloves between wound care on different parts of the client's body.
• A client has a leg wound that is in the second stage of the inflammatory response. For
what manifestation does the nurse assess?Purulent drainage
• A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut, limiting the client’s ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.
• A student nurse asks the nursing instructor what “apoptosis” means. What response by the
instructor is best? Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
• A preoperative nurse is assessing a client prior to surgery. Which information would
be most important for the nurse to relay to the surgical team? Use of multiple herbs and supplements
• Which statement about carcinogenesis is accurate? Tumor cells need to develop
their own blood supply.
• A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? Report of headache and stiff neck
• The nurse caring for oncology clients knows that which form of metastasis is the
most common? Bloodborne
• A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? "It helps prevent stomach ulcers, which are common after burns." [Show Less]