ATI (0001-0348) Flashcards
A client newly diagnosed with type 2 diabetes mellitus has returned for a 6-week follow-up visit. The nurse should know that which of the following behaviors indicates that the client has adapted successfully to a situational role change?
Monitors blood glucose once a day
After a client views a video on an operative procedure, the best practice for the nurse is to
give the client a handout outlining information relayed in the video.
Which of the following nursing actions best promotes client safety when transcribing providers’ orders?
Verify the order sheet contains the correct client indentification
A nurse is caring for a client who has a nursing diagnosis of impaired swallowing following a cerebrovascular accident (stroke). Which of the following nursing interventions is appropriate for this client?
Restrict fluid intake.
A nurse is caring for a client who gave birth 10 hr earlier. The client is in the takingin phase of psychosocial and maternal adaptation. Which of the following is the most appropriate nursing intervention at this time?
Listen to the mother’s verbalization of her pregnancy and birth experience.
A nurse is caring for a client following a thyroidectomy. For which of the following complications should the nurse assess the client?
Laryngeal stridor
A nurse is assessing a client who has a nasogastric feeding tube in place. Which of the following actions should the nurse take to prevent aspiration?
Keep the head of the client’s bed elevated at least 30° at all times.
A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching?
I will determine which muscles to contract by stopping and starting my stream of unrine
A nurse is caring for a client with a terminal illness. The nurse recognizes that the family’s priority need for support will most likely occur when
making decisions about measures to prolong life and provide comfort.
A nurse is developing a discharge plan of care for an older adult client on a rehabilitation unit following a cerebrovascular accident. Which of the following has the highest priority when planning care to facilitate a timely discharge?
Arranging for transportation
A client with HIV is admitted to the medical-surgical unit with a respiratory infection. The client’s family member requests that fresh flowers be placed in the room every day. Which of the following is the appropriate nursing action?
Teach the family that fresh plants of any type are prohibited.
Which of the following is the highest priority for the circulating nurse in maintaining a safe operating room environment?
Reviewing the preoperative assessment
A client with a tracheostomy is being sent home to be cared for by the spouse. The nurse should include which of the following information in discharge teaching?
How to properly operate the portable suction machine
During the first 24 hr following a soft-tissue injury to the right ankle, which of the following nursing interventions will help reduce the client’s discomfort?
Apply an ice pack to the ankle for 20 to 30 min at a time.
A nurse is caring for a client with a mental health disorder. The client is agitated, and the nurse is concerned that the client may become aggressive. Fearful for his own safety, the nurse escorts the client to a room and locks her inside against her will. This action
could result in charges of false imprisonment for the nurse.
When instructing a client with an L1-2 spinal cord injury regarding self-care adaptations, which of the following is an appropriate recommendation?
Adaptive devices are available to help you put on your shoes.
A 1-year-old child is prescribed ibuprofen after having a febrile seizure. The nurse should teach the parents that the best way to administer the medication is
a suppository.
Which of the following strategies best ensures that all nurses on staff have certain skills and knowledge?
Completing annual competence assessments
Which of the following manifestations should a nurse expect to find in a client whose blood glucose is 650 mg/dL?
Cool, clammy skin
A nurse is caring for a client diagnosed with depression who has been prescribed a tricyclic antidepressant. The nurse should recognize that which of the following client statements indicates an adverse effect that should be reported to the primary care provider?
I haven’t been able to urinate for several hours.
A client is scheduled for laparoscopic surgery at 1400. At 1100, the surgeon visits the client’s room and exits after 5 min with a signed informed consent form. The client reports to the nurse that he did not understand the surgeon’s explanation. Which of the following actions should the nurse take?
Explain the procedure to the client and complete documentation.
Upon admittance to the hospital, a client states she does not have a written advance directive. After completing the admission assessment, the nurse explains that the client should complete an advance directive because it
finalizes the client’s decisions regarding life-saving measures.
A nurse is providing care to a client with a head injury and suspected diabetes insipidus. Which of the following laboratory values should the nurse expect with a diagnosis of diabetes insipidus?
Urine specific gravity of 1.001
A nurse is caring for a client who is postoperative for a thyroidectomy. The client is reporting paresthesias and muscle spasms. The nurse should anticipate a prescription for which of the following medications?
Calcium chloride (Calciject)
A nurse is caring for a child who has just been admitted to the acute care medical unit. Which of the following laboratory findings should the nurse recognize as indicative of rheumatic fever?
Elevated creatine kinase and troponin
A nurse who is a first responder to a biological or chemical attack recognizes that decontamination should preferably be done
near the scene of exposure.
Anurse recognizes which of the following older adult clients as being at the highest risk for a fall injury?
A client with aphasia following a cerebrovascular accident
A hospital visitor is experiencing a tonic-clonic seizure while visiting a client. To prevent injury to the visitor, the nurse should
clear furniture from around the visitor.
A client has just been diagnosed with gestational diabetes and is prescribed insulin injections. She tells the nurse that she doesn’t want to give herself shots and asks why she can’t take a pill instead. Which of the following nursing responses is appropriate?
Pills used to treat diabetes are more likely to cause hypoglycemia.
A nurse is caring for a client who had a transurethral resection of the prostate and is receiving a continuous bladder irrigation. At the conclusion of the shift, the nurse collects the following data:
Oral intake = 5 00 mL
Bladder irrigant infused= 3,000 mL
Foley catheter drainage= 4,000 mL
Which of the following is the client’s urinary output?
4,000 mL
Which of the following findings should indicate to a nurse that a client has been effectively treated for Mycobacterium tuberculosis?
Sputum culture negative for acid fast bacilli
A client wants to review his medical chart, and he asks the nurse if he can see it. The nurse should tell the client that
his request to view his medical chart must be made in writing.
Which of the following is an appropriate nursing intervention to take when caring for a client in a crisis?
Help the client to refocus and find constructive ways to cope.
A nurse is caring for a client with thrombophlebitis. Which of the following interventions is appropriate for this client?
Elevate legs with a pillow under the knees.
A nurse is caring for four clients who are hospitalized. In which of the following client situations should the nurse intervene by notifying the primary care provider?
A client snores loudly and reports headache when awakening.
While assessing a client in labor, the nurse observes the umbilical cord protruding from the client’s vagina. After calling for assistance and requesting that the primary care provider be notified, the nurse should immediately
position the client on her side and insert a sterile gloved hand into the vagina to take pressure off the cord.
A nurse is planning discharge teaching for the parents of a child with cystic fibrosis. Which of the following is most important for the nurse to emphasize?
Provide an environment that is free of allergens.
A nurse is caring for four clients, each of whom has an assistive device. Which of the following clients needs further instruction?
A client who locks both of his elbows when using his crutches to ambulate to the bathroom
When performing a mental status examination, a nurse should recognize that which of the following client findings indicates impaired cognition?
The client frequently asks, “Where am I?”
A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take next?
Reevaluate the client for an ET cuff leak.
A client is receiving epoetin alfa (Epogen) for treatment of anemia secondary to bone cancer. Which of the following client findings indicates the hematopoietic growth factor treatment has been effective?
Hemoglobin levels are within normal limits.
While visiting a family health clinic, a 19-year-old client requests information regarding the correct use of condoms. Which of the following statements made by the nurse is correct?
When using implanted contraceptive methods, condoms should also be used to protect against STDs.
A nurse is caring for a client with an upper gastrointestinal bleed. When performing a saline lavage through a nasogastric tube, the nurse should use which of the following techniques to prevent gastric aspiration?
Instill a minimum volume of 300 mL ofNS.
One of the clients assigned to a nurse has become medically unstable. Due to the time the nurse must now spend with this client, provision of care to other assigned clients will be difficult. Which of the following tasks could be delegated to assistive personnel (AP)?
Feeding a client who has a history of aspiration
A nurse is providing palliative care to a client and his family. Which of the following statements by the family indicates an understanding of palliative care?
The nurse will help control my father’s pain.
When providing safe care to a client being placed in restraints, which of the following nursing interventions is appropriate?
Insert two fingers between the client and the restraint after it is secured to ensure that the fit is loose enough.
Staff nurses on a medical unit implement a new program to improve cost effectiveness. Prior to exiting clients’ rooms, the nurses are to ask, “Is there anything I can get you before I leave?” Which of the following suggests that the new program is effective at reducing costs?
The staff nurses are spending less time at the bedside performing non-nursing tasks.
A nurse is caring for a child with a new onset of seizures who is about to undergo an electroencephalogram (EEG). Which of the following should be included in teaching the child and parents about the procedure?
Wash the child’s hair with mild shampoo prior to the procedure.
A nurse is caring for four clients who are scheduled for surgery today. Which of the following indicates that a client needs further intervention before surgery?
A client whose INR is 2.1 and PTT is 2 times the normal value
A nurse is caring for a client with a peripherally inserted central catheter (PICC). Prior to initiating an infusion through the PICC line, the nurse should take which of the following actions?
Confirm placement via chest x-ray.
A client is taking an opioid for pain postoperatively. He tells the nurse, “I haven’t had a bowel movement for 3 days, and I normally go every day.” Which of the following is the nurse’s most appropriate response?
A side effect of your pain medication is constipation. I will contact the doctor for a laxative prescription.
A nurse is performing initial rounds and assesses four clients. Which of the following occurrences should be documented and reported to the charge nurse immediately?
A client with diabetes mellitus has a blood glucose level of 150 mg/dL.
A nurse is directing the care of multiple clients. In determining how to best utilize the skills of a team that includes RN s, licensed practical nurses, and assistive personnel, which of the following is the most important information source?
Team member job descriptions
A nurse is caring for a client who has a urinary tract infection and has been receiving a broad-spectrum cephalosporin. Which of the following serum laboratory results indicates medication effectiveness?
WBC 9,200/mm³
A nurse is caring for an infant receiving oxygen via an oxygen hood. Which of the following client findings indicates that the client may be experiencing oxygen toxicity?
Substernal retractions
A nurse is providing discharge instructions to the parents of a newborn. Which of the following instructions regarding newborn safety is most important for the parents to understand?
Secure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle.
A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and a blood pressure of 180/90 mm Hg. Which of the following nursing actions should the nurse take first?
Administer pain medication.
A nurse should give priority to which of the following interventions when initiating IV antimicrobial therapy?
Review the client’s allergy history.
A child is 6 hr post abdominal surgery. One hour ago, the nurse administered morphine sulfate for pain. Which of the following behaviors is the best indicator that the pain medication has been effective?
Points at smiling face on rating scale
A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should
assist the client into the lithotomy position.
Which of the following interventions should the nurse include in the client’s plan of care to prevent development of phlebitis from a peripheral IV?
Flush the IV site every 4 hr.
A client’s orders include D5W 1,000 mL over 8 hr. The tubing drip rate is 10 gtt/mL. The nurse should adjust the flow rate to which of the following infusion rates?
21 gtt/min
A client is to receive 300 mg phenytoin (Dilantin) by mouth twice daily. The medication is available in a 125 mg/5 mL solution. How many milliliters should the nurse administer for each dose?
12 mL
A client with gestational hypertension is experiencing toxic effects from magnesium sulfate therapy. The nurse should anticipate administering which of the following medications to counteract the adverse effects?
Calcium gluconate
A newborn whose mother had gestational diabetes is hypoglycemic at birth. Which of the following actions should the nurse take?
Feed the newborn as soon as possible.
A nurse in an outpatient clinic is reviewing the results of four clients who have had screening procedures. Which of the following results indicates a need for client follow-up?
Fasting blood glucose level 250 mg/dL; female, age 47
A nurse is teaching a client with GERD about omeprazole (Prilosec ). Which of the following indicates a need for further teaching?
I should take it before breakfast.
Which of the following statements made by a client indicates that the client has developed trust with the nurse?
I would like to discuss a painful experience.
After giving 5 mg of morphine to a client from a 10 mg vial, the nurse should do which of the following with the remaining morphine?
Dispose of it with a licensed witness.
A nurse is caring for a client with bone cancer who is taking morphine sulfate to control generalized pain. The primary care provider also prescribes amitriptyline (Elavil). The nurse recognizes that the rationale for the addition of amitriptyline is to
decrease agitation.
A 2-month-old infant has received immunizations at a well-child appointment. The nurse should instruct the parent to report which of the following within the first 48 hr?
A fever greater than 38.9° C (102° F)
An older adult client who resides in a long-term care facility reports insomnia and excessive daytime sleepiness. To promote rest for the client, the nurse should plan to perform which of the following interventions?
Assess the client’s usual bedtime routine.
A client’s advance directive states that he does not want dialysis when his health condition worsens. The client is currently competent and agrees to dialysis. The nurse should
schedule the dialysis since the client is able to make his own decisions.
Which of the following best indicates to a nurse that a terminally ill client’s spiritual needs are being met?
The client is able to discuss his thoughts concerning death with the nurse.
A nurse should recognize that which of the following older adults is at the highest risk for social isolation?
client who is oxygen dependent and lives alone in an apartment community
When performing a 12-lead ECG for a client, the nurse should take which of the following actions?
Place the client in Fowler’s position with arms resting comfortably at his sides.
A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is most appropriate?
Lubricants in moisturizing soaps may interfere with adhesion of the appliance.
A nurse is providing dietary instruction to a client diagnosed with acute cholecystitis. The nurse recommends which of the following as the most appropriate food choice for lunch?
Fresh broccoli and cauliflower
A nurse is caring for a client admitted with a spinal cord injury. After the nurse immobilizes the spine, which of the following is the next priority?
Assess respiratory pattern and effort.
Following a gastric resection, a client experiences a cramping sensation, increased pulse rate, dizziness, and nausea after eating a meal. To help reduce these symptoms, the nurse instructs the client to
restrict liquids during, at least 1 hr prior to, and after meals.
A nurse is performing a nonstress test on a client who is pregnant at 41-weeks gestation. The nurse notes that the client is having contractions every 2 to 3 min. Which of the following actions should the nurse take first?
Place the client in a side-lying position.
A nurse is caring for an older adult client who has chronic renal failure and is prescribed acetaminophen for fever. The nurse can expect that the dosage will be
less than the recommended dose.
A nurse is caring for a client immediately following surgery under general anesthesia. The client’s pain is being managed by morphine via a patient-controlled analgesia pump. The nurse should give priority to assessing the client for which of the following adverse medication interactions?
Decreased respiratory rate
A nurse is preparing an adolescent client for allergy skin testing. The nurse should expect the adolescent to select which of the following instructional approaches?
Individual instruction by a nurse regarding skin testing in a quiet learning environment
A nurse is caring for a client with herpes zoster. Which of the following statements indicates that the client needs more teaching?
I will take ibuprofen for my pain.
A client is transferred from the PACU to a private room on the surgical unit. During the nurse’s initial assessment, the client begins to vomit. Which of the following is the nurse’s priority intervention?
Position the client on her side.
A primary care provider is about to discontinue a client’s chest tube without giving the client’s preprocedure pain medication time to be effective. Which of the following actions should the nurse take at this time?
Inform the provider that not enough time has passed for the medication to work effectively.
A 4-year-old child is being seen in the emergency department after being involved in a motor vehicle crash. The child has a fractured humerus and will be placed in a synthetic cast prior to discharge. Which of the following is an appropriate intervention to include in parent teaching?
Check movement and sensation of the extremity frequently.
Parents of an infant ask for information regarding immunization schedules. The nurse should suggest that the parents obtain the most current immunization schedule from which of the following sources?
Centers for Disease Control Web site
A nurse is caring for a client who has permanent drooping on the left side of the face following a cerebrovascular accident (stroke). The client refuses to see any family members. Which of the following interventions will best help the client adapt to this body image change?
Educate the client about short- and long-term effects of stroke.
A nurse is taking the blood pressure of a client who has come to the clinic for a blood pressure check due to suspected hypertension. Which of the following techniques is appropriate?
Position the client’s arm above the level of the heart while obtaining the reading.
A nurse is caring for a client following a total hip arthroplasty. The client’s legs are too large for antiembolic stockings/devices. Which of the following interventions should the nurse expect to implement?
Elevate the foot of the bed.
A nurse should recognize that which of the following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis?
A 7-year-old boy recovering from impetigo
A nurse is caring for a client with an epidural catheter for opioid administration for pain control. When the nurse is changing the dressing, which of the following is the highest priority?
Preventing catheter dislodgment
Which of the following client findings indicates a need for complementary therapy?
A client with diabetes mellitus is noncompliant with his diet.
Which of the following findings best indicates that outcomes have been met for a client who has been physically abused by her spouse?
The client reports that she has a safety plan in place and will implement it when necessary.
An RN has delegated a Foley catheter insertion to a licensed practical nurse (LPN) for a client who has been unable to void for 10 hr. Which of the following outcomes will require further intervention by the RN?
The LPN reports 60 mL of clear, straw-colored urine output.
A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about the disorder. To prevent a sickle cell crisis, the nurse emphasizes the importance of
adequate hydration.
A client who is receiving phenytoin (Dilantin) for seizure disorder has been prescribed isoniazid (INH) and rifampin (Rifadin). Which of the following should the nurse conclude if the client develops ataxia and incoordination?
The client is showing evidence of phenytoin toxicity.
A nurse is caring for a client who has undergone a modified radical mastectomy. The client has two Jackson-Pratt drains. The nurse should
empty and compress the reservoir.
A client who has a second-degree bum tells the nurse that the dressing changes are very painful. Which of the following nursing interventions is appropriate?
Teach the client relaxation techniques to be used during dressing changes.
A nurse is preparing an older adult client for discharge. As the nurse is going over the discharge instructions, the client says, “Can I stay at the hospital for a couple more days? My daughter is supposed to stay with me, and I’m worried because we don’t always get along.” The appropriate action by the nurse is to
report a possible case of older adult abuse to the state authorities.
When providing nursing care and support for a client with a gambling dependency, which ofthe following is the·most appropriate intervention?
Establish client goals and have the client explain what actions he will take to prevent and manage gambling relapses.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of abuse?
Notify the appropriate state agency about the client’s condition.
A nurse is receiving a change-of-shift report on four clients. Which of the following clients is at the greatest risk for developing an infection?
A client who takes prednisone every morning
A nurse delegates the task of ambulating a client to an assistive personnel (AP). At the end of the shift, the nurse discovers that the client has not been ambulated. This situation could have best been avoided if the nurse had
emphasized to the AP the importance of ambulating the client.
A nurse is planning health promotion education for adolescents. Which of the following interventions is appropriate?
Distribute detailed visual handouts regarding the impact of smoking on lifelong health.
A nurse is discussing circumcision with a new mother. Which of the following actions should the nurse take to ensure informed consent?
Explain the consent form for the procedure.
A client is diagnosed with an acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin in the emergency department. Which of the following findings indicates that the client is experiencing a satisfactory response to these interventions?
The client’s aPTT is two times the control.
A nurse is caring for a client with hyponatremia and heart failure. The assessment reveals moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following should be the nurse’s priority intervention?
Administer diuretics.
A nurse is assessing a client who has been taking an estrogen-progestin oral contraceptive. Which of the following side effects should the nurse recognize as being related to an excess of estrogen?
Weight gain
A nurse is teaching a client stress management techniques. Which of the following client statements indicates effective learning?
I write in my journal to express my feelings, even though my grammar is bad.
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique?
Balancing the bottle on the sterile basin while pouring the liquid
A nurse is providing teaching to a family of an infant with decreased cardiac output due to congenital heart disease. Which of the following strategies regarding care for this infant should be included in the teaching?
Observe for signs of hunger, such as sucking on fists, in order to feed the infant before crying occurs.
A nurse is providing discharge teaching to a client following a total hip replacement. Which of the following statements made by the client indicates an understanding of the discharge teaching?
I won’t cross my legs when I sit in a chair.
A nurse is providing client teaching regarding sumatriptan (Imitrex). Which of the following client statements indicates that the client understands the expected effects and appropriate uses of this medication?
I should use this medication daily to prevent reoccurrence of my migraines.
A nurse is instructing an adolescent recently diagnosed with type 1 diabetes mellitus about self-blood glucose monitoring (SBGM). Which of the following is the most important reason the adolescent should perform SBGM?
Modification of insulin regimen to maintain normal glucose levels
A nurse is assigned to care for a client who is managing his own continuous ambulatory peritoneal dialysis treatment at home. The nurse is unfamiliar with the client’s plan of care. The nurse should
review the procedure and care standard.
Which of the following assessment findings indicates a complication following an angiogram with a femoral approach?
A decrease in pedal pulse from baseline
Which of the following clients is appropriate for the nurse to refer to speech therapy for a swallow evaluation?
An older adult who has difficulty taking in fluids
Which of the following is an activity a nurse should engage in to assist in disaster preparedness?
Participate in community drills and mock events.
A nurse is caring for a client who has right-sided weakness after a recent cerebrovascular accident (stroke). The nurse should
provide neurosensory stimulation for the client.
Following a cerebrovascular accident (stroke), a client experiences right hemiparesis and expressive aphasia. Which of the following best promotes communication among health care team members?
Swallowing precautions are posted above the head of the client’s bed.
Which of the following clients should a nurse evacuate first when a fire occurs?
A client who is bedridden and hearing impaired
Which of the following nursing interventions should a nurse implement when using music therapy to assist a client in controlling his pain?
Plan for sessions that last about 30 min to maximize the therapeutic value.
A client is diagnosed with a pulmonary embolism. Which of the following client findings is consistent with effective treatment?
The client reports feeling less anxious.
A nurse is developing a plan of care for an older adult client with hearing loss. Which of the following interventions should be included in the plan?
Get the client’s attention before speaking.
A nurse is providing teaching to clients in an outpatient mental health setting. Which of the following client statements indicates understanding of the teaching?
A client taking sertraline (Zoloft) states she knows she will not feel the full benefits for 2 to 3 months.
A nurse is caring for a client who is undergoing external radiation treatment for cancer. Which of the following should be included in the client teaching?
Wear protective clothing when out in the sun.
A client is admitted with second-degree bums over 30% of her body. She is prescribed 4,080 mL/24 hr of lactated Ringer’s solution IV. Which of the following infusion rates will assure that the client will receive ½ of the total volume within the first 8 hr?
255 mL/hr
A charge nurse is attempting to resolve a conflict between two nurses who both insist that the charge nurse favors the other when making daily assignments. Which of the following is the most effective conflict-resolution strategy that the charge nurse can use?
Collaborate with the two nurses when making assignments.
A nurse is caring for a client with pneumonia who has just been diagnosed with HIV. The nurse learns that the client’s partner seldom visits since the diagnosis. Which of the following strategies is appropriate for the nurse to implement?
Refer the matter to a social worker.
A nurse is caring for a client with Crohn’s disease. Which of the following breakfast menu items is appropriate for this client?
Whole grain cereal
A nurse is caring for an older adult client in a long-term care facility. Recent laboratory values show increased hemoglobin, hematocrit, and urine osmolarity. These findings suggest
dehydration.
A client is admitted to the emergency department following a motor vehicle crash. Which of the following findings is consistent with hypovolemic shock?
Change in level of consciousness
A labor nurse is caring for a woman in active labor who does not speak English. The client grimaces with each contraction but remains silent. The nurse should first
assess the client’s pain level with a visual analog scale.
When performing triage during a community disaster, a nurse should understand that the highest priority clients in a disaster situation are those who have lifethreatening injuries and
have a high probability of survival after stabilization.
A nurse is caring for a client with heart failure who is receiving D5NS at a rate of 125 mL/hr. The client reports shortness of breath. Which of the following actions should the nurse take first?
Decrease the IV fluid flow rate.
When reviewing the ABGs of a client who has uncompensated respiratory alkalosis, the nurse should expect to see which of the following results?
pH of 7.46
A nurse is performing a dressing change on a client with an open wound. Which of the following actions should the nurse take to dispose of the soiled dressing?
Put the dressing in a biohazard bag and tie the bag securely.
A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse assess first?
A client receiving oxygen via a nonrebreather mask with an SaO2 of 88%
A charge nurse must instruct two staff nurses in the use of a new infusion pump. He knows from previous experience that these two nurses are kinesthetic learners. Which of the following teaching methods should the charge nurse use?
Ask the nurses to perform a return demonstration of pump setup and use.
A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?
PaCO2 level of 55 mm Hg
A nurse should recognize and document which of the following as an expected finding for a client with a central vascular access device?
The catheter tip is in the lower third of the superior vena cava per x-ray.
A nurse is observing a new graduate, who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the graduate nurse indicates a need for the nurse to intervene?
Uses the TPN IV tubing to administer the client’s next dose of antibiotics
A nurse is teaching a client about surgical wound care at home. Which of the following statements by the client indicates an understanding of wound care?
I will call my doctor if I notice drainage from the wound.
Which of the following nursing actions is most likely to promote independent dressing in a client who has Stage 1 Alzheimer’s disease?
Give instructions to the client and then leave the room.
Which of the following assessment findings indicates that a client is experiencing a complication from conscious sedation?
A client undergoing a bronchoscopy experiences hypoxemia.
A client develops anxiety and tachypnea at the start of a blood transfusion. The nurse should take which of the following actions next?
Stop the blood transfusion.
A client meets with the nurse for her first prenatal visit. The client’s last menstrual period began on April12. Using Nagele’s rule, the nurse determines that the client’s expected delivery date is
January 5.
A nurse refuses to care for a client who frequently comes to the emergency department requesting pain medication. Which of the following actions should the charge nurse take?
Discuss the nurse’s feelings related to this client.
A home health nurse is performing an initial assessment of a client’s home. Which of the following must be immediately removed by the nurse?
Frayed extension cords
Which of the following client findings is an indication that a client with bipolar disorder is about to experience a relapse?
Is restless and has changes in sleep pattern
A client presents to the birthing unit reporting the onset of contractions. Which of the following client findings is consistent with false labor?
Intermittent, painless contractions
A nurse is caring for four clients who are using various assistive devices. Which of the following client findings suggests a need for further education regarding appropriate use of an assistive device?
A client asks his wife to place his dentures under his pillow after cleaning them.
A nurse is caring for a client admitted to the emergency department following a motor vehicle crash. The Glasgow coma scale rating is 15. The nurse should recognize that the client
is oriented times three.
A client is brought to the emergency department with a full-thickness bum of the thorax. Which of the following is the most important nursing intervention?
Initiate IV normal saline.
A client has a repair of a retinal detachment. Which of the following interventions should the nurse anticipate implementing to prevent complications during the recovery period?
Administer a stool softener to prevent straining during defecation.
A nurse is caring for an infant with gastroenteritis. Which of the following assessment findings should the nurse report to the primary care provider?
The infant has sunken fontanels and dry mucous membranes.
A client undergoing surgery is receiving succinylcholine and nitrous oxide. The client’s temperature abruptly rises to 39.4° C (103° F), and the client’s muscles become rigid. The nurse should initially take which of the following actions?
Discontinue administration of the neuromuscular blocking agent.
A client is diagnosed with HIV. Which of the following should the nurse plan to teach the client to help prevent the spread of HIV infection?
Use a condom with a petroleum-based lubricant.
A nurse can help ensure that a client’s privacy is protected during a pelvic examination by
providing a gown and drape, asking the client to undress from the waist down, and then leaving the room for a few minutes.
A nurse is interviewing the husband of a woman who has been admitted in the manic phase of bipolar disorder. The husband states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is most therapeutic?
Could you tell me a little more about what has been happening with your wife at home?’’
Which of the following nursing interventions has the highest priority in promoting a therapeutic milieu for a group of clients?
Encourage appropriate social behaviors.
A nurse removes an IV catheter from a client who developed phlebitis at a peripheral IV site. Which of the following is the most important piece of data that should be included in the documentation?
Time of day
A nurse is assessing a client’s need for restraints. Which of the following is an acceptable reason for the use of physical restraints?
Protecting others from a client’s aggressive behaviors
A nurse is caring for four clients who are receiving respiratory medications. The nurse should notify the primary care provider about which of the following client findings?
A client receiving inhaled salmeterol (Serevent) reports a peak expiratory flow in the yellow zone.
A client who is a data programmer presents with reports of tingling and numbness of the index and middle fingers of the right hand. Which of the following should be included when teaching about activities to help prevent carpal tunnel syndrome?
Sit with back erect, feet on floor, and shoulders slightly rounded.
A client is receiving internal radiation therapy for cervical cancer. Which of the following statements made by the client indicates understanding of the therapy?
When I leave the hospital, I need to avoid the sun.
A nurse is caring for a client who is receiving IV potassium chloride for hypokalemia related to the use of potassium-wasting diuretics. The nurse evaluates hypokalemia treatment as successful if which of the following is noted?
Pulse rate becomes regular.
A nurse is caring for a client who has a medication order that is unfamiliar to the nurse. Which of the following actions should the nurse take first?
Check a medication reference.
To ensure proper client identification when providing care, the best nursing action is to
check clients’ identification bands.
A nurse is assessing a client for uterine atony. To assess for atony, the nurse should
palpate the client’s uterus for consistency and placement.
A nurse reviews laboratory studies for a client with dyspnea. An elevation in which of the following values indicates that the client’s dyspnea is related to heart failure rather than myocardial infarction?
B-type natriuretic peptide
A community health nurse is discussing injury prevention with teachers in a day care. Which of the following developmental factors places toddlers at risk for injury?
Oral fixation
Which of the following assessment findings should the nurse expect to find in a 2- year-old child?
Nontender, protruding abdomen
A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTis ). Which of the following should the nurse include as a risk factor for developing a UTI?
Using perfumed toilet paper
A client has received a transfusion of 250 mL of packed red blood cells. Which of the following findings indicates that the client is responding positively to the transfusion?
The client’s hemoglobin level increases following the transfusion.
The roommate of a university student who was recently hospitalized for bacterial meningitis asks if she is in danger of developing the infection. Which of the following is the appropriate response by the nurse?
Bacterial meningitis is spread by contaminated food or water; therefore, infection is unlikely.
A nurse is planning care for a client hospitalized with COPD who is experiencing persistent fatigue. Which of the following is an appropriate nursing action to address the client’s fatigue?
Arrange for rest periods between interventions.
A nurse is caring for a client who is a rabbi, which of following activities should bP included in plan of care to incorporate religious belief?
Assess client’s nutritional needs and preferences
Which of the following laboratory findings indicates the client is at risk for complications following a thorancentesis?
-Albumin 2.1
A nurse is caring for a client with nursing diagnosis impaired swallowing following a CVA, which of the following nursing implementation is appropriate for the client?
Place in Fowler’s
A nurse is caring for a client who gave birth 10 hours earlier. The client is in the taking in phase of maternal adaptation. Most appropriate intervention at this time?
Listen to mother’s verbalization of pregnancy and birth experience
A client is receiving radiation therapy as treatment for breast cancer. Which findings indicates possible development of hypercalcemia as a complication of radiation therapy
gastric distress and renal calculi
A client is receiving several different medications during an inpatient stay in a health care facility. Which medications should be suspected when client begins experiencing severe diarrhea?
Celphamine
A female client with several stage 4 pressure ulcers is undergoing treatment as prescribed by the wound care consultant. Which findings to the nurse indicates that client’s plan of care needs revision and consultant should be contacted?
loss of 2.3 kilograms(5bs) over past 7 dat
A nurse is caring for a client in a long term care setting that provides restorative care which of the following is appropriate when assessing client’s ability to perform ADLs’
monitor client’s ability to perform hygience care
A client is admitted with suspected GERD upon receiving the client’s admission laboratory results the nurse notes a troponin level of 0.6ng/DL. Based on this finding the nurse should expect which of the following additions to the client’s pland of care
provide oxygen via nasal cannula
A client with HIV admitted to the med surg unit with a respiratory infection, the clien’ts family members requests fresh flowers be placed in the room everyday. Which of following is the appropriate nursing action?
teach that family fresh plants of any type are prohibited
During the administration of conscious sedation, a client respiratory rate of 9/min. Client does not respond when asked to lift her right hand, which nursing action is indicated by these findings
actminister oxygen and agents
A nurse is caring for a client with AIDS who is antiviral treatment. Which lab values indicate the client is responding to treatment
increased CD4 and lymphocyte count
A nurse is caring for 4 clients who have been prescribed various nonpharm interventions, the nurse should intervene first for which of the following clients.
client who is 3 days postop, prescribed icepacks, and rates his pain at 5 out of 10
A hospice nurse is making home health visits, which of following findings indicate effective coping
client is communicating funeral preferences to family members
A client hospitalized with pnemonia is demonstrating difficulty talking and remaining asleep
environment with reduced noise and light
A one year old child is prescribed ibuprofen when having a febrile seizure. Nurse teach parent best way to admin med is
elixir
When preparing client for lumbar puncture
lie on your side with knees to your stomach
Which of foil manifestations should nurse expect to find whose blood glucose of 650
fruity breath odor
Nurse is caring for client with depression, prescribed TCA antidepressant, which of following statements indicated adverse effect that should reported to primary care provider
my eyes have been sensitive to sunlight lately (look it up)
A client is scheduled for laproscopy surgery at 1400, At 1100 surgeon visits and after 5 min with informed consent. Client states doesn’t understand surgeons explanations, what should nurse do?
call surgeon and requests he return to client’s room to provide clarification
Upon admittance to hospital a client states she does not have a written advance directive. After completing ad miss assess, nurse explains should complete an adv directive because:
guides primary care provider in planning care for individuals in accordance with their wishes
A nurse is evaluating effectivess of nonpharm mangt for a client. Which of following findings indicate interventions is effective
client falls asleep after back massage
EXHIBIT? A nurse is caring for client post op. Client reports pain level of 10/10 at 8:30, based on the pain assess finding and the client’s information provided the nurse should take which of the following actions next.
call the primary care provider for analgesic intervention
A client is admitted to the !CU wj head injury, the ICP is being monitored via an intraventricular catheter, which should nurse include in client’s POC?
avoid overstimulation of the client
A nurse who is the first respondent to a biological attack, recognizes that decontamination should preferably be:
near the site of the exposure
A nurse should carefully monitor client’s taking Furosemide (Lasix) and which of the following medications:
Gentamycin
Nurse is assessing a client who is 36 weeks gestation, which should nurse report to provider?
3+ deep tendon reflexes
When developing a client’s trust, the nurse should give priority to which of the following nursing interventions
ensure the confidentiality of the client’s information
A nurse is collaborating with other staff nurses to determine staffing needs for a surgical unit, currently the hosp is usihg a client’s identification to determine staffing levels. Which of the following data is most important in planning for optimal staffing?
time of day that most client’s return from the operating room
A nurse is caring for a client who is febrile. Reduce fever by giving cooling blanket, which indicates having adverse reaction?
shivering
Client wants to review medical chart, ask nurse to see it, nurse tells client:
you have a legal right to review your medical chart
Which of foil is appropriate nursing interven to take when caring for client in crisis
Help client refocus and find constructive ways to cope
Client is receiving oxytocin (pitocin) to augment labor, which findings indicate to nurse that current dose of oxytocin should be maintained
fetal heart rate increase of 15bts per min with contractions
A nurse is dev a discharge care plan for client who has osteoporosis to prevent injury nurse should instruct client to
perform weight bearing excercises
while assessing a client in labor the nurse observes that the umbilical chord protruding from the clients vagina after calling for assistance and requesting that the primary care provider be notified the nurse should immediately
position the client on her side and insert a sterile gloved hand into the vagina to take pressure off the chord
A nurse is preparing a client for discharge with a? presecribtion for aldactone. The nurse should instruct the client to limit the intake of which of the following foods
banannas and citrus fruits
A nurse is to perform a dressing change for a client with a burn wound identify the sequence the nurse should follow. (this one you put in order in the box)
- medicate with analgesic
- remove previous dressing
- assess for edema draininage and discharge
- apply a thin layer topical antibiotic ointment as prescribed
- observe wound as prescribed
when performing a mental status examination the nurse should recognize that which of the client finding indicate impaired cognition
the client frequently asks where am I
A nurse is working on an orthapedic surgical unit … where slide back chairs are used to assist client to get out of bed and increase mobility. there are not enough chairs to serve all the clients, which of the following actions is important for the nurse to take
Has the need for further equipment to meet client care demands
a client if revievieng a epoetin alpha (epogen) for treatment of anemia secondary to bone cancer which of the following client findings indicate hematopoesis growth factor treatment has been effective?
hemoglobin level are with in normal limits
while visiting a family health clinic a 19 year old … regarding the correct use of condoms. Which of the following statements made by the nurse is correct
when using implanted contraceptive methods condoms should also be used to protect against STD’s
a nurse is assessing a client who is near the end of her first trimester during the routine prenatal exam. When checking to determine whether or not the fetal heart rate can be detected the nurse should
Move the fetal scope along the midline just above the pubis while applying firm pressure
A client is admitted with a history of transient ischemic attacks. To prevent injury while hospitalized, the nurse should
complete a fall risk assessment upon admission
A nurse is providing pallative care to client and family. Which statement by family indicates understanding ofpallative care
the nurse will help relieve my father pain
A nurse is caring for a client with GERD, which of foil assessment findings should nurse expect to find
atypcial chest pain
A client is prescribed 500 mg penicillin JM, the 2gm of pen in vial should be diluted with 10m! of normal saline before admin the dose, nurse should check that there are how many ml in syringe
2.5
A nurse is caring for a child with a new onset of seizures who is about to undergo an EEG, which of the following should be included in teaching child and parents about the procedure
wash child’s hair with mild shampoo prior to procedure
a nurse is caring for 4 clients who are scheduled for surgery today, which a following indicates that a client needs further intervention b4 surgery
client’s INR 2.1, PTT is 2 times the normal value
Which of the following assessment following indicate proper use of crutches by a client?
client’s positions hands on grips with elbows slightly flexed
A nurse is planning discharge teaching for a client who will continue receiving chemo for treatment of leukemia in the outpatient clinic. Which offoll should nurse include
avoid salads, raw fruits and veggies
Which of the fall nursing actions is an example of safe cost effective care
remove unused IV infusion pump from the client’s room
An adolescent who is being seen in the outpatient clinic reports she has had a low grade fever, headache, sore throat, swollen lymph nodes for about four days. This morning she developed a pinkish red macular popular rash on her face and neck. Which of the following is an approprate nursing action
isolate her from any pregnant woman
A client is being transferred from one health care facility to another. To ensure continuity the nurse who is transferring the client should give priority to inclusion of which of the following information
an assessment of the client’s tolerance of physical activity
A client in ESRD has a serum potassium of 6.2mEQ/L. The nurse should anticipate implementing which of folio interventions first?
initiate continuous cardiac monitoring
A nurse is providing discharge instructions to the parents of a newborn. Which of following instructions regarding newborn safety is most important for the parents to understand?
secure the newborn in a rear-facing approved infant car seat when riding in a motor vehicle
A nurse is caring for a client on his first day after having knee surgery. Morning assessment reveals a pain level of 8/10 and bp of 180/90mmHG. Which of the following nursing actions should nurse take first?
admin pain med
A nurse should give priority to which of the foil interventions when initiating IV anitmicrobial therapy
review the clients allergy history
A school nurse is performing scolosis screening. Which of fall clinical signs will be evident in a student who has scolosis?
uneven shoulder and pelvic height
A nurse is positioning a client for Cesearen birth. To prevent a compromise in placental blood flow during the intraoperative period, the nurse should
place a wedge under one of the client’s hips
A nurse is providing care to a client who has Hep A. Nurse should recognize which of following nursing actions poses risk for transmission of the disease
emptying the fecal matter
During a well child visit for a toddler. The nurse should include which of the folll when discussing age specific growth and dev?
it is normal for your child to … say whose and …… and pronounce single syllabus words at this age
A nurse is evaluating whether an in service for the organiz structure of the unit was effective. The staff have been heard complaining about the charge nurse not being assigned clients. The nurse can accurately deduce from the responses that the
inservice needs to be repeated so staff are more clear on the proposed change
A client is to receive a puendedal block while giving birth. The nurse should expect that a puendal block will
diminish pain in the perineum
Which of the following statements by a parent of a newborn indicates that discharge teaching regarding care of a circumcision has been effective?
I will give my baby sponge until the circumcison has healed
A nurse is providing discharge instructions to the parent of a newborn. The nurse determines parent requires further teaching regarding use of a bulb syringe if she states
I should insert the syringe in the center of his mouth
The nurse is teaching a client with GERD about omerprazole (Prilosec). Which of the following indicates a need for further teaching?
it will decrease the pH level in my stomach
A nurse is caring for a client wj an indewelling urinary catheter. Which of the foil actions should nurse take to provide appropriate catheter care?
Provide perineal hygiene at least twice a day
A nurse is teaching a client who just had a repair of retinal detachment. Which of foil client statement indicates a need for further teaching
I can do quiet activities such as reading or sewing
A nurse is caring for a client who is receiving continuous tube feedings via a NG tube. The client appears restless and abdomen is distended. Which offoll actions should nurse take first?
check the residual volume
During assessment of a client with pneumonia. The nurse documents the following findings:
Client alert, oriented, restless
BP is 148/65mmHG
Oxygen saturation of 86% (while on 02 at 2L/min per nasal cannula
Heart rate is 94/min
Respirations is 24/min
The client is currently receiving IV at 100ml/hour and morphine sulfate. Which of the following actions should the nurse take next.
increase the oxygen flow rate
A nurse is caring for a client with fingerstick blood glucose level of 42mg/DL. Which of the foil findings is consistent with the lab values
anxiety and confusion
A nurse notices an unfamiliar staff member entering the obstetrical unit. Which of the following is the most appropriate intervention
stop staff member and verify identification
A nurse is caring for a client with Crohns disease receiveing TPN. Which of the foil findings is most indicative that the client is responding positively TPN therapy.
average weight gain of 1Kg/ day
A nurse is caring for a client who had a recent spinal cord injury and is quadriplegic. Which of the following assessment finding is a complication related to immobility
crackles in the lower lung fields
A client had major abdominal surgery 24 hours ago. Which of the following is the best indication that postop nursing intervention have been effective in preventing resp complications
client is able to breath deeply and to forcefully cough while splinting
A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Nurse should recognize which of following indicates an adverse affect that must be reported to the primary care provider
client is observed displaying a shuffling gait while walking in the hall
A nurse is planning care for an older adult client with a cognitive disorder such as Alzheimer’s Which of the foil interventions should be included in the client’s plan of care. Select all that apply
- give client one simple direction at a time
- establish eye contact and use touch when communicating with client
- reinforce orientation to time, place, and person.
(unsure about answer)
A nurse is caring for a client who has just received the first dose of Lisinopril. Which of the following is appropriate nursing intervention
provide standby assist when client gets out of bed
Following a gastric resection, client experiences a cramping sensations, increased pulse rate, dizziness, and nausea, after eating a meal. To help reduce sx nurse instructs client:
restrict liquids during, at least one hour prior to, and after meals
A diet reports to an RN that another nurse smells like alcohol Which of the following should the RN take next:
Gather any additional information from the client and then notify the nurse manager
A nurse for an older client who has chronic renal failure is prescribes acetaminiphen for fever. The nurse can expect that the dosage will be:
less than recommended does
A nurse is admitting a client who is taking prednisone 10 mg daily for 10 mg for 10 months. Which of the following findings indicate a side effect of this medication therapy.
thin extremities with obesity of the stomach
A wife is acting as a primary care giver to her spouse with Alzheimer’s disease who is homebound. The home health nurse recognizes signs of ineffective coping and caregiver distress. The nurse should take which of the following actions initially:
Provide information on local support groups for the wife to attend
The nurse is caring for a client with herpes zoster. Which of the following statements indicate the clients needs more teachmg?
I will apply astrigent compresses to the lesions three times a day
A Child with diabetes mellitus has a blood glucose level of 343mg/DL the nurse anticipates which of following action
Request a bilingual Spanish-speaking female translator through the facility.
A nurse is caring for a child with iron deficiency anemia. Which of the following lab values should nurse expect to find?
decreased hematocrit
A nurse is receiving the past medical history of a client admitted for agina. Which of the following is a risk factor for angina?
hyperlipidemia
Which of following findings best indicate that outcomes have been met for a client who has been physically abused by her spouse?
client reports that she has a safety plan in place and will implement it when necessary
Nurse caringfor a client admitted with …. fluid volume excess due to heart failure. Which of foil assessment findings validates client’s hypervolemia has been resolved?
BUN 8mg/DL
Nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which should nurse recognize as an expected finding?
child believes the person will return
A client who is receiving Phenytoin (Dilantin) for seizure disorder has been prescribed INH and Rimfapin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?
client is showing evidence of phenytoin toxicity
A nurse is caring for a client who has undergone a modified radial mastectomy. A client has to jackson Pratt drains. The nurse should
empty and compress the reservoir
A client who has a second-degree burn tells the nurse that the drsg changes are very painful. Which of the foil nursing interventions is appropriate?
teach client relaxation techniques to be used during drsg changes
Which of the following nursing actions appropriately maintains client confidentiality?
a nurse removes an open chart from the nurse’s station counter and places it on the chart rack .
When providing nursing care and support for a client with a gambling dependency. Which of the following is the most appropriate intervention.
Establish clients goals and have the client explain what actions he will take to prevent and manage gambling relapses
A client in labor is undergoing a vacuum assistive birth. Which fthe following should the nurse perform at the conclusion of the procedure.
Perinial assessment for trauma (other option missing)
A nurse delegates the task of ambulating to a client to an assistive personnel at the end of the shift the nurse discovers that the client has not bee.en ambulated. The situation could have been best avoided if the nurse had:
emphasize to the AP the importance of ambulating the client
Which of the following interventions by the nurse to is most appropriate to decrease potential infections for a child with leukemia who is receiving chemotherapy.
Screen and limit the childs visitors
A client uses prescribed hydrocodone(vicodin) insisting oxycodone perkasett has resolved pain in the past. Knowing that the prescribed provider prefers hydrodone which of the follwing actions should the nurse take.
inform the prescribing provider of clients preference
a·nurse is caring for an infant with gatroentiritis which of the following assessment findings should the nurse report to primary care provider?
infant has decreased appetite and irritable
A nurse is caring for a client been discharged on warfarin, which of the following home medication should the nurse question?
asprin 81mg
A client is diagnosed with an acute Ml and is being treated with a thrombolytic agent and iv heparin in the emergency department which of the following finding indicates that the client is experiencing a satisfactory response to this intervention
the client aptt is 2 times the normal value
A nurse is assessing the fontanells in a 8 month old infant which of the following is an expecxted finding
anterior font. Should be open
The nurse is assessing a client brought to the hospital psych services by a law enforcement officer the client has disorganized incoherent speech with … association and religious content client has flat affect, poor hygenen, repeptitive hand gestures the nurse recognizes these signs and symptoms as being most consistant with which of the following
schizophrenia
A client who is insulin dependent is .. which determines ifthe clients blood gluclose level is controlled? ·
h a1c of 6.5
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client which of the follo:wing actions by the nurse breaks surgical aseptic technique
balancing the bottle on the sterile basin while pouring the liquid
A nurse is providng teaching for a family of an infant with decreased cardiac output with congenital heart disease which of the following for providing care should be included in the teaching
observe for signs of hunger such sucking of fist … in order to feed infant before crying occurs.
The nurse is providing discharge teaching to a client following a total hip replacement which of the indicates a proper understanding of discharge instructions
I wont cross my legs when I sit in a char
A nurse is caring for a client following surgery for open angle glaucoma which of the following should be included in the clients care plan
instruct client to wear a patch over the affected eye
A nurse is instructing an adolescent recently diagnosed with type 1 DM about self blood glucose monitoring which of the following reactions that adolescents should adolescents perform ·
coorelation of blood glucose with activity
A charge nurse on a cardiac step down unit is receiving a float nurse from a l&D unit which of the following assignments should the charge nurse give to the float nurse
a client who is 3 days post cardiopulmonary artery bypass surgery
An older adult client moves in with her daughter and her family. the daughter tells the visiting nurse that there is a great deal of stress in the family because the father is interfering with parental decisions, the nurse should take which of the following actions to help integrate the older adult client into the family structure
facilitate a family meeting to discuss and resolve issues related to changes in the family structure
A nurse is caring for a client with esoph. Varicies the client is vomiting bright red blood which of the following actions should be taken to protect the client.
suction the oropharynx
Which of the following activites should a nurse engage in to assist in disaster prep redness
participate in community drills and mark … ?
A nurse is caring for an adult client with chronic anemia who is to receive a transfusion of 1 unit of packed RBC’s which of the following actions is appropriate
flush the blood transfusion tubing with normal saline prior to the transfusion
Following a CVA a client with right hemiparesis and expressive aphasia which of the following best promotes communications among the health care team members
interedisciplinary team meetirig are held on a regular basis
A nurse is caring for a client to has undergone alcohol detox to promote alcohol abstinence which of the following should be included in the clients plan of care
promote the development of new coping strategies to prevent relaspses
A client has a diminished gag reflex is recieivng 60 % 02 through partial rebreather ask and has received haldol prn for anxiety. The client is trying to climb out of bed with increased respiratory rate and loud rhonchi which of the following actions should the nurse take first
perform nasotracheal suction and monitor clients reponse
When reviewing the lab results of a client with primary hypothyroidism the nurse should expect an increase in which
thyroid stimulating hormone TSH
A nurse should instruct an assitive perscinelle to provide a verbal report immediately upon acquisition of which of the following client information
finger stick blood gluclose of client receieving sliding scale insulin
Which of the following nursing action best promotes safety when using chemotherapeutic agents
wear personal protective equipment when handling agents
A client is admitted with second degree burns over 30 percent of her body she is prescribed 4080 ml per 24 hour of lactated ringer solution IV which of the following infusion rates will ensure that the client will receive half of the total the first 8 hours
255 ml per hour
a nurse is montitoring a client with a prescription of continusou IV heparin at 1000 units per hour the IV bag from the pharmacy contains 50 units per ml. thorught the shift the nurse should ensure that the IV infusion pump is delivering the heparin at the rate of how many ml per hour
20
A nurse is assisting a client with acute glomerular nephritis. To choose menu choices for break fast which of the follwing is a good choice
bagel
A nurse is caring for a client with chrons disease which of the following breakfast menu options is appropriate
pouched eggs
A nurse is caring for an older adult client in a long term care facility, recentllab values shows increased hemoglobin, hematocrit, and urine irregularity which finidings suggest anemia
dehydration
A client is admitted to the ED following a motor vehicle crash which of the following findings is consistailt with hypovolemic shock
change in LOC
A nurse is preparing discharge instructions with a post op clients with transverse abdominal incision. Which of the following indicates nurses teaching is effective
the client lists indications to call the primary care provider such as incisional warmth and redness
A student nurse has been instructed on proper body mechanics to prevent personal injuries during client lifts and transfers which of the following is correct info for the nurse to include
when a client up in bed tighten abdomen muscles.
A nurse is reviewing the chart of 4 clients who have come into a public health clinic based on the life style choices of each of the clients which of the following clients are in need of further assessments
a client who jogs everyday and applies ice to his shins for 20 mins after running
A nurse is caring for a child following a tonsillectomy which of the following findings indicates that the client is experiences hemmorage
frequent swallowing
A nurse should recognize and document which of the following as an expected finding for a client with a central vascular access device
the catheter tip is in the lower 3rd of superior vena cava per xray
A client with pneumonia I feel like an elephant is on my chest the client is weak and unable to walk after the nurse initiates chest pain protocol, which of the following is priority diagnostic test
chest x-ray
The nurse is performing an admission history on a client who is being admitted to a mental health unit a. The client has a diagnosis of borderline personality disorder. based on this diagnosis, the nurse should assess the eli net for which of the ffing
a pattern of unstable ………… in which the client alternatively idealizes and devalues others
Which of the following nursing action is most likely to promote independent dressing in a client who has stage 1 alzhemiers disease
lay out the appropriate clothing for the client each day
The client is receieving gentamyacin pre op of ruptured appendix which of the following assessment finding indicate an adverse effect of medication
creatin 2.3
A nurse notes that a client rythym has changed to a fib which of the following finding should be reported immediately
chest pain
A client meets with the nurse for a first prenatal visit. The clients last menstrual period began April12 th. Using naegals rule the nurse determines EDD is?
Jan 19
Nurse caring for client with new colostomy which of the following interventions is appropriate for preventing skin break down.
cut the opening of the cut-to- fit pouch 1- 1/6 inch larger the stoma
A nurse is assessing a client in skeletal traction for a fractured tibia which of the following clinical findings indicates altered tissue perfusion ofthe affected extremity
pedal pulse 1+
Which of the following client findings of a client with bipolar disorder is about to relapse
restless and has changes in sleep pattern
A nurse has just received change of shift report. Based on the info provided which of the following clients should be assessed first
a client who was jut given a glass of orange juice for low glucose level
A nurse is instructing a parent of an infant with a cleft lip/ pal at which of the following feedking techniques is appropriate to include in the teaching
burp frequently during feedings
A nurse should recognize that which of the following clients is ready for a rehab referral.
client who is 2 weeks post spinal chord injury.
a client is brough to ED with full thickness burn on thorax which of the following is the most important nursing intervention
obtain ABG
A client uses prescribed hydrocodone(vicodin) insisting oxycodone perkasett has resolved pain in the past. Knowing that the prescribed provider prefers hydrodone which of the follwing actions should the nurse take.
inform the prescribing provider of clients preference.
a nurse is caring for an infant with gatroentiritis which of the following assessment findings should the nurse report to primary care provider?
infant has decreased appetite and irritable
Nurse caring for client in preterm labor to receives two doses of bethamethasone 24 hours apart the nurse should tell the client that the purpose of the medication is to decrease the risk of
new born respiratory distress
A nurse shoule recognize that which of the following clients needs a referral for PT
a client with left sided weakness due to CVA
A nurse can help ensure a clients privacy is protected during pelvic exam by
providing a gown and drape, askingthe client to undress from waste down and leaving the room for a few minutes .
A client has been taking glucocortocoid for severe rheumatoid arthritis which of the following client statements indicates a need for further education
I will immediately quit taking the medication if I have Gi distress
A home health nurse is assessing the home environment of a client with alzhemiers disease which of the following should be corrected
extension chord placed under rug
A nurse is caring for a client in the ICU who is on mech vent when a fire starts in the room after turning off o2 supply which action should nurse take next
ventilate with ambu bag and evacuate the room
A 12 year old child is scheduled for tonsillectomy in 2 weeks outpatient scheduling nurse should plan to meet the psuchosocial needs of child by a. explain hospitalization morning of surgery
allowing child to participate dirung informed consent from parents
A nurse in the ED is caring for a child who is experiencing an acute asthma attack Child is receving albuteral by nebulizer for which of following adverse effects should nurse monitor
tachycardia
A nurse is teaching a client about measures to decrease stress incontinence the client is most likely to benefit from
kegel exercise
An orientation program is being developed for new staff which is most beneficial in assisting new staff for work place
paired work with expert staff nurse
Nurse is caring for a client who is receiving iv potassium choride for hypok+ related to use k+ wasting diuretics, the nurse evaluates hypokalemia treatment as successful if which of the following is noted
pulse rate becomes regular
Nurse caring for client with medication order unfamiliar to the nurse. Which of the foll actions should nurse take first
check a medication reference
A client develops a lower left leg DVT following surgery. This development indicates a need for which of the following additions or revisions to client’s plan of care
apply warm moist compress to affected extremity
Nurse is assessing client for uterine atony. To assess for atony, the nurse should
palpate the client uterus for consistency and placement
A nurse is evaluating teaching effectiveness for client to be discharged on Digoxin. Which client statement indicates need for further instruct
I should expect to experience some nausea while taking medication
ln caring for a client with central line catheter a nurse should take which of the foB actions
after removing drsg compare the external catheter length with original length at insertion
A nurse is caring for a client who was given 10000 U of IV heparin rather than prescribed 1000 U, the nurse should give priority to which of the foll actions
assess for signs of bleeding
Client diagnosed with COPD is being discharged home with oxygen therapy. Upon discharge the nurse provides instructions to the client on how to use the equipment. Which of following statements by client indicates understanding of nursing instructions?
l should use water based ointment around my nostrils if they get dry
A charge nurse is making client assignment on a med surg unit for the day. Which of the foil tasks is appropriate for the charge nurse to delegate to a LPN on the unit
programming a PCA infusion pump
The roommate of a univ student recently hospitalized for bacterial meningitis ask if she is in danger of developing the infection. Which of the foil is the appropriate response by the nurse
bacterial meningitis can be prevented if antibiotics are taken after exposure to infection
A nurse is planning care for a client hospitalized with COPD who experiencing persistent fatigue. Which of following is an appropriate nursing action to address client’s fatigue
arrange for rest periods between interventions
