2. A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility,
... [Show More] which of the following actions should the nurse take?
Occlude the IV tubing above the injection port
3. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
Paradoxical pulse
4. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. 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.)
-Assess the appearance of the wound.
-Cleanse the wound with 0.9% sodium chloride irrigation
-Obtain the specimen from granulation tissue of the wound.
-Place the swab in the culture tube.
-Cover the wound with a sterile dressing
5. A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following Indicates that the client is in the latent phase of labor?
The cervix is dilated 2 cm.
6. A nurse on an orthopedic floor is completing the morning assessments on several clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)?
A 24-year-old male who has a casted femur fracture
7. A nurse receives change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess first? A client who had a hip arthroplasty reports pain and erythema in their calf
8. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?
A client who has a traumatic arm amputation
9. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to assistive personnel?
Perform chest compressions during cardiac resuscitation.
10. A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)
Answer: A
11. 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.
12. A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take?
Wipe excess medication from the outer canthus toward the nose
13. A nurse is planning to delegate client assignment to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?
Collecting the urine specimen
14. A nurse discovers that the wrong dosage of a medication was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied?
Veracity
15. A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?
Clopidogrel
16. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?
Observe the client's level of mobility.
17. A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contractions of the head and neck muscles. Which of the following medications should the nurse administer?
Diphenhydramine
18. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?
Fever
19. A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general adaptation syndrome and should expect which of the following findings? Hypoglycemia
20. A nurse is caring for a client who is taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? Uric acid level
21. A nurse is caring for a client who is taking alprazolam. Which of the following prescriptions should the nurse clarify with the provider?
Ceftriaxone
22. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? Speech-language pathologist
23. A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?
Moisturize dry skin areas on the client every other day.
24. A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?
The child has increased sputum production.
25. A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
Hypothermia
26. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?
Monitor for abdominal ascites.
27. A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include? “Apply a teething product containing benzocaine to your child's gums before bedtime.”
28. A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. Which of the following information should the nurse include in the teaching? Estrogen therapy decreases the risk for breast cancer.
29. 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
30. A nurse is caring for a client who is receiving continuous feedings via NG tube. Which of the following actions should the nurse take?
Check the client's gastric residual every 4 hr.
31. A 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
32. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
Hallucinations
33. A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?
. Hold the bottle of sterile solution with the palm over the label while pouring
34. A charge nurse is instructing a group of newly hired nurses about medications to promote fetal lung maturation. Which of the following medications should the nurse include in the instructions?
Betamethasone
35. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
Place the newborn 45 cm (18 in) from the light source.
36. 36.
37. A nurse is using Nägele's rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the client's last period was October 4. What is the expected delivery date? (Provide the date using four numerals, the first two for the month and the second two for the day. For example, January 2 = 0102.)
0711
38. A nurse is assessing the vital signs of a newborn who was born 8 hr ago. Which of the following findings requires intervention by the nurse?
Temperature 36.2°C (97.2° F)
39. A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride IV.
40. A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
WBC 3,000/mm3
41. A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? A client who is 2 days postoperative following a colon resection
42. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
Generalized edema
43. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
Hyperemesis
44. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for metabolic alkalosis?
A client who has kidney failure
45. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take?
Observe the system for an air leak.
46. A nurse is setting up a sterile field for a dressing change on a postoperative client. Which of the following actions should the nurse plan to take to maintain the sterile field?
Open the first flap of the sterile package away from the nurse's body.
47. A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective?
“I will use my cell phone on the ear opposite of my pacemaker.”
48. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? (Select all that apply.)
✓ Newborn swallowing sounds are audible while breastfeeding.
✓ Newborns' stools are yellow and seedy after 7 days of breastfeeding.
✓ Maternal breasts become soft following feedings.
49. A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?
Begin prophylactic treatment with ciprofloxacin.
50. Four clients present to an emergency department. The nurse should plan to see which of the following clients first?
A 50-year-old client who has slurred speech, is disoriented, and reports a headache
51. A nurse is providing teaching to the guardian of a 5-month-old infant about introducing new foods. Which of the following instructions should the nurse include in the teaching? “Introduce a new food every 5 to 7 days.”
52. A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say?
“Has your partner physically hurt you before?”
53. A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect?
Peritonitis
54. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action?
Notify the facility operator.
55. A nurse is teaching a group of newly hired nurses about placenta previa. Which of the following client findings should the nurse include?
Bright red vaginal bleeding
56. A nurse is teaching a client who has a low-literacy level about home management of diabetes mellitus. Which of the following actions is appropriate?
Show the client an educational video.
57. A nurse is performing a vision screening for a client. Which of the following findings should the nurse identify as an Indication that the client has cataracts?
Increased opacity of the lens of the eye
58. A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation?
Sucralfate 1 g PO 1 hr ac
59. A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding?
Dry, raised facial rash
60. A nurse is caring for a school-age child who has a blood pressure of 88/50 mm Hg and develops septic shock. Which of the following medications should the nurse expect the provider to prescribe?
Dopamine
61. A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take?
Pad the side rails of the bed.
62. A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium extended-release tablets. Which of the following actions should the nurse take?
Administer the medication with applesauce.
63. A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider immediately? Coughing and wheezing after eating
64. A community health nurse is preparing to collect data to study the health of a local community. The nurse should plan to obtain information about which of the following factors during a windshield survey?
The availability of religious facilities
65. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse
Tell the client to avoid drinking fluids 1 hr before bedtime. [Show Less]