exit pdf mj Flashcards
- A nurse is caring for a client who is 2 days following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression to independence and mobility for the client?
A. Keep loose absorbent dressing around incision site.
B. Encourage the client to use the overhead trapeze.
C. Caution the client to avoid a prone position while in bed.
D. Maintain abduction of the client’s limb with a pillow.
B. Encourage the client to use the overhead trapeze.
A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior to administering immunization. The nurse should recognize respiratory rate is 30/min. This indicates that the respiratory rate is?
A. Respiratory rate is a manifestation of respiratory infection
B. Within the expected range
C. Result of cold stress
D. Manifestation respiration depression
B. Within the expected range
A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take?
Encourage the client to be assertive
A charge nurse in the long-term care facility notices the smell of alcohol from one of the nurse’s breath. Which oc the following actions should the nurse take first?
A. Assign the client to the remaining staff
B. Remove the nurse from the client care area
C. Document objective findings from the situation
D. Call the supervisor to ask for another nurse
B. Remove the nurse from the client care area
A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks ago. Which of the following findings should the nurse expect?
A. Increase growth of fine body hair
B. Fundus is halfway palpable
C. White Blood Cells are elevated
D. Reported Lochia Alba
D. Reported Lochia Alba
A nurse is supervising an assistive personnel. Which of the following actions by the AP indicates an effective use of client care materials?
A. Wears clean gloves when assisting client with oral care
B. Empty sharp container when it is full
C. Wearing an N95 when bathing a client who has C-Diff
D. Returns unopened food items from the clients tray to the client
A. Wears clean gloves when assisting client with oral care
A nurse is preparing to administer spironolactone and lisinopril to a client who reports anxiety, dyspnea, and weakness of the leg. Which of the following actions should the nurse take first?
A. Withhold the prescribed medication
B. Document the client’s manifestations
C. Administer insulin per facility rules
D. Call the provider
A. Withhold the prescribed medication
A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states, “I’m thinking of stopping the treatment.” Which of the following responses should the nurse make?
A. “Why do you think that would be a good choice?”
B. “Tell me more about what you are thinking.”
C. “I would feel the same way if I were you.”
D. “You’ll be cancer-free after you complete your treatment.”
B. “Tell me more about what you are thinking.”
The nurse is caring for a client who reports having a decreased in fetal movement following an external cephalic version 6 hours ago. The nurse identifies the fetus in Right Occipital Anterior position. Where should the nurse place the fetal heart monitor?
The nurse should put the fetal heart rate monitor above the umbilicus and to the right of thew abdomen.
A nurse is RT with a client who is 35 weeks gestation who will undergo a contraction stress test. WOTF information should the nurse include in the teaching?
A. We will apply warm, moist cloths to your breasts
B. We will perform internal monitoring of your baby
C. You should expect the test to take 2 hours
D. You will lie flat on your back for the test
D. You will lie flat on your back for the test
A nurse is collecting data from a client who represents the facility and who reports vomiting. WOTF findings indicate that the client is experiencing Fluid Volume deficit?
A. Orthostatic hypotension
B. Brisk Capillary Refill
C. Bradycardia
D. Polyuria
A. Orthostatic hypotension
A nurse is reinforcing dietary teaching for a client who is 37 weeks gestation and has gestational hypertension. WOTF foods should the nurse recommend? (SATA)
A. Sourkauret
B. Raw apple
C. Ham
B. Cooked carrots
E. Lettuce salad
B. Raw apple, B. Cooked carrots
A client who has cancer is being discharged to home with hospice services. The client has a
prescription for oxycodone for pain control. WOTF medications should the nurse remind the client to take regularly to prevent a common adverse effect of this medication?
A. Ranitidine
B. Docusate Sodium
C. Lorazepam
D. Gabapentin
B. Docusate Sodium
A nurse is caring for an adolescent client who has been hospitalized for several weeks. WOTF actions should the nurse take relative to the client’s developmental stage?
A. Arrange for uninterrupted visitations with friends
B. Invite the patient’s parents to stay overnight in the daughter’s room
C. Encourage the client’s friends to being favorite books to read
D. Provide the client with a variety of jigsaw puzzles
A. Arrange for uninterrupted visitations with friends
A nurse is RT with a parent of a preschool age child who has a new diagnosis of varicella. WOTF statements indicate an understanding of the teaching?
A. I will give my child a bubble-bath every day
B. I will apply an antipruritic cream to my child’s skin
C. I will give my child an antibiotic for 10 days
D. I will apply alcohol to my child’s skin to dry out the lesions
B. I will apply an antipruritic cream to my child’s skin
A nurse is caring for a client who is experiencing urge incontinence and limited dexterity. WOTF
actions should the nurse take?
A. Establishing urinary habit program
B. Instruct the client about bladder compression
C. Instruct the client about self catheterization
D. Limit daily fluid intake
A. Establishing urinary habit program
A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. WOTF information should the nurse include in the teaching?
A. You will feel pressure when I inflate the catheter balloon
B. You cannot drink fluids for hour hours after the procedure
C. You will have a leg bag to collect the urine
D. You will need to urinate before
D. You will need to urinate before
A nurse at a long-term care facility is reviewing the PoC of a client who has a prescription for mitten restraints. WOTF tasks does the nurse assign to the assistive personnel?
A. Instruct the client’s family about the purpose of the restraints
B. Determine the circulatory status of the affected extremity every 2 hours
C. Evaluate the need for the client to remain in restraints
D. Assist with ROM of the hand
D. Assist with ROM of the hand
A nurse is RT with a client who has primary open-angle glaucoma and a new prescription for Timolol eye drops. WOTF statements by the client indicates an understanding of the teaching?
This medication will darken the color of my eyes
I should check my heart rate while taking this medication
I should take iron supplements with this medication
This medication will improve my vision
I should check my heart rate while taking this medication
A nurse is obtaining a health history from a client who wants to take oral contraceptives. WOTF
findings is the nurse’s priority?
Irregular periods
Smoking
Asthma
Obesity
Smoking
A home health nurse is preparing to set up a continuous passive motion machine for a client who
is post-op following a total knee replacement. WOTF actions should the nurse respond to take first?
Align the knee joint with the frame joint of the CPM machine
Inspect the CPM machine and electrical cords for possible damage
Place the CPM machine in extension and pad the surface with sheep skin
Set the degree of flexion and extension on the CPM machine
Inspect the CPM machine and electrical cords for possible damage
A nurse is preparing to administer morphine 30mg to a client who reports pain. Available
morphine is 20mg/mL
1.5mL
A nurse is RT about hand hygiene to a newly licensed nurse. WOTF information should the nurse include in her teaching?
Dry hands starting from forearm to fingers
Use hot water to wash hands
Interlace the fingers while rubbing hands together
Apply friction to hands for 10 seconds
Interlace the fingers while rubbing hands together
A nurse is reinforcing dietary teaching with a client who experienced a myocardial infarction. The nurse should encourage the client to limit WOTF?
Saturated fats
Dietary fiber
Omega-3 Fatty Acids Complex
carbohydrates
Saturated fats
A nurse is RT with the family of a client who is terminally ill about the grief process. WOTF information should the nurse include in the teaching?
Anger towards the health care staff is expected
Anticipatory grieving prolongs the grief process
The grieving process should be complete within a year
The stages of grief occur in sequential order
Anger towards the health care staff is expected
A nurse is collecting data from a client who has diabetic Ketoacidosis. WOTF should the nurse expect?
Fruity breath
A nurse in the long term facility is caring for an older adult client who has a history of hypertension. WOTF findings should the nurse recognize as an indicative sign of a Transient Ischemic Attack?
Epigastric Pain
Seizure activity
Sudden loss of vision in one eye
Pain radiating down the left arm
Sudden loss of vision in one eye
A nurse is planning care for a client who recently attempted suicide. WOTF actions should the nurse plan to take?
Keep the client’s door closed when he is in the room
Limit the client’s personals to room only cologne
Observe the client’s behavior every 2 hours
Ensure the client swallows each dose of medicine
Ensure the client swallows each dose of medicine
A nurse is caring for a client who has upper gastrointestinal bleed. WOTF actions should the nurse take first?
Prepare the client for an upper endoscopy
Obtain a prescription for blood transfusion
Insert an NGT for lavage
Check bowel sounds
Check bowel sounds
A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis.
Nuchal rigidity
A nurse is transcribing a prescription from the provider. The prescription reads Gentamicin 2 gtt OD q4h. WOTF information should the nurse clarify with the provider?
Time
Medication
Route
Dosage
Dosage
A nurse is reinforcing discharge teaching with a client whose post-op and who has a prescription of oxycodone. WOTF information should the nurse include to prevent constipation?
Take a stool softener at bedtime
Reduce daily fiber intake
Limit water to 4 glasses per day
Decrease physical activity
Take a stool softener at bedtime
A nurse is reinforcing teaching with a parent of a child who has a new prescription for ferrous sulfate in liquid form. WOTF statements by the parent indicates an understanding of the teaching?
I will notify the provider if my child becomes nauseated
I will give the iron through a straw
I will notify the provider if my child’s stools are tarry
I will give the iron with milk
I will give the iron through a straw
A nurse is collecting data from a client who has cholecystitis. WOTF findings should the nurse
expect?
Pain radiating to the jaw
Pain in the right upper abdomen
Increased abdominal discomfort prior to meals
Discomfort with urination
Pain in the right upper abdomen
A nurse is caring for a 3 year old child at a well-child visit. The parents report that their son has
been playing with imaginary friends. WOTF responses should the nurse make?
How many hours per day does your child watch TV?
This is a common behavior for children at this age
You should seek family counseling if this behavior continues
Children have imaginary friends to gain attention
This is a common behavior for children at this age
A nurse is assisting with the physical examination on a 7-year-old child. WOTF options should the
nurse take?
Have a parent remove the child’s outer clothing
Perform the most invasive procedures first
Explain the purpose of the equipment used
Explain findings during the examination
Explain the purpose of the equipment used
A nurse is delegating client care assignments. WOTF tasks should the nurse assign to the assistive personnel?
Reinforce teaching on how to use the glucometer for a client who has diabetes
Monitor a client’s sacral pressure ulcer to determine need for dressing
Reposition client who is experiencing increased ICP
Apply an antiembolic stocking for a client who is 2 days post-op
Apply an antiembolic stocking for a client who is 2 days post-op
A nurse is caring for a client who had a femoral popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate the pulses in the affected leg. WOTF actions should the nurse take?
Place the client in high-fowler’s position
Implement passive ROM
Notify the charge nurse about the findings
Apply a warm, moist pad to the extremity
Notify the charge nurse about the findings
A nurse is caring for a client who has multiple sclerosis and has a new prescription for baclofen.
WOTF indicates that the medication is having its desired effect?
Improved alertness
Improved dexterity
Increased appetite
Increased blood pressure
Improved dexterity
A nurse is assisting with the prenatal examination of a client who is at 8 weeks gestation. The
nurse notices a purplish color of the vagina
Chadwick’s sign
A nurse is caring for a client who recently gave birth to her first child. The baby is crying and the client states, “I can’t seem to do anything right, what should I do?” What is the nurse’s best response?
Let me show you how to swaddle and cuddle him, then you try
I’ll take him back to the nursery
If I turn him on his side maybe it’ll go to sleep
Babies need to cry soon after they are born to develop their hormones
Let me show you how to swaddle and cuddle him, then you try
A charge nurse is observing a newly licensed nurse perform suction on a tracheostomy. Which of the following should the charge nurse intervene?
Suctioning for 30 seconds
A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage?
Help her not to move early
Breathe in deeply at the beginning of contractions.
Gently stroke her abdomen at the start of her contractions
Apply steady pressure with her pubis to her sacral area
Apply steady pressure with her pubis to her sacral area
A nurse is reinforcing discharge teaching to the family of the client who has Alzheimer’s Disease. The client has wandering behaviour and the family is concerned about safety at home. Which of the following instructions should the nurse include?
Replace door knobs with ones containing simple locks
Keep the client’s shoes at the front door
Contact Law enforcements if unable to locate the client
Obtain a medical bed with side rails to use at night.
Replace door knobs with ones containing simple locks
A nurse is reinforcing teaching with a mother who is breastfeeding her 3 week old newborn. Which of the following instructions should the nurse include in the teaching?
Encourage the newborn to take a pacifier
Offer the newborn supplemental formula twice daily
Feed the newborn every 2-3 hours
Feed the newborn for 30 minutes.
Feed the newborn every 2-3 hours
A nurse is collecting data from a child during a well child visit. Which of the following actions should the nurse take when checking the child’s oculomotor function?
Pupils are equal and react to light.
Pupils are equal and react to light.
A nurse is caring for a client who delivered by C-section 1 day ago. The client requests non pharmacological interventions to manage pain when changing position. Which of the following responses should the nurse make?
Use breathing techniques when changing positions
Splint incisions with pillow when changing position
Change positions as little as possible
You can apply counter pressure to your back with each position
Use breathing techniques when changing positions
A nurse is caring for a client who has a new diagnosis of heart failure and has a new prescription
for digoxin. The nurse should monitor which of the following for an adverse effect?
Insomnia
Hyperkalemia
Seizures
Visual Changes
Visual Changes
. A nurse is caring for a client who has anorexia nervosa. At home the client exercises frequently each day. Which of the following interventions should the nurse implement?
Encourage the client to continue on an exercise routine
Monitor the difference in weight before and after exercise
Allow the client to snack throughout the day
Observer during meals.
Observer during meals.
A nurse is reinforcing teaching to a client who is to start taking ferrous sulfate elixir. Which of the following statements shows client understanding of teaching?
I will mix medication with water
I will report tarry stools to my doctor
I can prevent nausea if I take the medication on an empty stomach
I can prevent constipation if I take milk with this medication
I will mix medication with water
A charge nurse at Emergency Department recommends that a client should be discharged in response to mass casualty disaster. Which of the following clients should the nurse recommend?
A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation
A client who has Diabetes and ketonuria
A client who has hypertension and a new onset of slurred speech
A client who has aortic stenosis and 2 kg weight gain
A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation
A nurse is caring for a mother who is breastfeeding her newborn 1 week after delivery. Which of the following types of stools from the newborn should the nurse expect?
Watery
Firm
Seedy
Gelatinous
Seedy
A nurse is reinforcing teaching about foot care of a client who has Diabetes. Which of the following statements indicates an understanding of the teaching?
I should not use moisturizers on my feet
I should wear the same shoes all day
I can remove my own callus with a pumice stone
I should shake out my shoes before I put them on
I should shake out my shoes before I put them on
A charge nurse is discussing about confidentiality of a client; about sharing the client’s medical record. Which of the following people should the nurse identify as an appropriate person to share client’s information with?
Client’s partner
Social Worker
Client’s Employer
Nurse from another unit
Social Worker
A nurse is assisting to monitor a client who has preeclampsia and is receiving an infusion of
Magnesium Sulfate. Which of the following findings should the nurse expect to stop the infusion and report to the charge nurse?
Diaphoresis
Facial Flushing
Urine Output 40 mL/hr Respiratory rate 10/min
Respiratory rate 10/min
A nurse is providing skin care for a 14-year-old adolescent who is in skeletal traction for a fractured femur. Which of the following actions should the nurse take? Select all that apply.
Massage reddened bony prominences
Check skin every 2 hours
Cleanse skin with soap-free
agents
Use a draw sheet to move client
Elevate the HOB to a 90 degree angle
Check skin every 2 hours
Cleanse skin with soap-free
agents
Use a draw sheet to move client
A nurse is caring for a client who has prescription for Warfarin. What laboratory values should the nurse check?
INR
A nurse in a mental health facility is observing two clients playing cards in the day room. One of the clients becomes agitated and throws the cards on the ground. Which of the following actions should the nurse take first?
Encourage client to express their feelings.
Assist the client to resolve the issue
Administer haloperidol
Place the client into a quiet area
Place the client into a quiet area
A nurse is reviewing the medical record for a child who is scheduled for a Varicella Immunization. Which of the following findings should the nurse recognize as a contraindication.
Chemotherapy
A nurse is reinforcing teaching about sterile technique with a newly licensed nurse. The nurse should include in the teaching. Which of the following procedures requires sterile technique?
Suctioning Tracheostomy
A nurse is reinforcing teaching to a client who has Hypertension about dietary measures to
control blood pressure. Which of the following food selection shows an understanding of teaching?
Grilled cheese
Ham sandwich
Baked chicken
Tomato soup
Baked chicken
A nurse is caring for a client following an electroconvulsive therapy. What action should the nurse monitor?
15 minutes disorientation
A nurse is reinforcing teaching with a client who is planning on becoming pregnant about the dietary intake need to reduce the risk of neural tube defect. Which of the following foods is a priority to include in the teaching?
Rice
Cooked Spinach
Orange juice
Eggs
Cooked Spinach
A nurse is caring for a client who has new prescription for ferrous sulfate. Which of the following
findings should the nurse monitor the client?
Orthostatic Hypotension
Gastrointestinal Distress
Decreased Clotting Time
Orange Urine
Gastrointestinal Distress
A nurse is providing care for a client who has cystic fibrosis. Which of the following effects is a
therapeutic effect of administering pancreatic enzymes?
Reduced fat in the stools
Decreased sodium excretions
Improved respiratory function
Improved absorption of vitamin B and C
Improved respiratory function
A nurse is reinforcing discharge teaching with a parent of a newborn. Which of the following
statements indicates an understanding of the teaching?
“I will use hydrogen peroxide on the cord during each diaper change.”
“I will fold the diaper just below my baby’s cord.”
“I will wash the cord with warm soapy water.”
“I will apply petroleum jelly daily to my baby’s cord.”
“I will fold the diaper just below my baby’s cord.”
A nurse is preparing to administer acetaminophen 50 mg PO to an infant. Available is 80 mg/0.8 mL. How many mL should the nurse administer to the infant?
0.5 mL
A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take?
Ensure the weights are hanging freely
A nurse is caring for a client who is receiving continuous bladder irrigation following a
Transurethral resection of the prostate. Which of the following findings should the nurse report immediately to the provider?
The client suddenly develops bladder spasms
The nurse observes continuous bright, red urinary output
The client passes small clots in drainage bag
The nurse notes drainage flow rate has slowed
The nurse observes continuous bright, red urinary output
Anurseiscollectingdatafromanadolescentclientwhoisexperiencingsexualabuse.Whichof
the following shows that the client is using the defense mechanism of suppression?
“My mother is the real reason for it all because she doesn’t live in the real world.”
“Sometimes, I get angry about it.”
“I drink beer as often as I can so I don’t have to think about it.”
“I have to take some of the blame because of the way me and my friends dress.”
“I drink beer as often as I can so I don’t have to think about it.”
A nurse is assisting with discharge planning for a group of clients. Which of the following clients
should the nurse recommend for a home care referral.
Adolescent who has tibial fracture and requires crutches.
Older adult client who has heart failure and lives alone.
Young adult who has a substance abuse disorder
Middle age adult who has a mastectomy and requires radiation
Older adult client who has heart failure and lives alone.
A nurse is caring for a client who is taking multiple medications about the possible interactions. Which of the following members of the interdisciplinary team should the nurse make a referral to?
Advance practice nurse
Psychologist
Social worker
Patient-care technician
Advance practice nurse
A nurse on the postpartum unit is reinforcing teaching with a client whose baby is 1 day old about the development of sensory behavior. Which of the following statements by the client indicates an understanding of teaching?
“My baby can hear my voice when I talk to him.”
“My baby will recognize the odor of my breath within couple of weeks.”
“My baby will gradually feel me touching his skin.”
“My baby’s eye prefer bright light.”
“My baby can hear my voice when I talk to him.”
A nurse is caring for a client who has an indwelling catheter for a urinary drainage. Which of the following actions should the nurse take?
Instruct the client to hold the draining bag at waist height.
Coil the tube on the bed above the drainage bag.
Secure the tubing to the lower abdomen with adhesive tape.
Collect a sterile specimen from the drainage bag.
Coil the tube on the bed above the drainage bag.
A nurse is on a mental health unit is caring for a client who expresses anxiety. The nurse
promises to walk with the client everyday. Which of the following ethical principles is the nurse displaying?
Fidelity
A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact
isolation. Which of the following actions by the AP should the charge nurse intervene?
Remove gloves last when taking off PPE
A nurse is reinforcing discharge instructions with a client who had a myocardial infarction. Which of the following statements indicates an understanding of the teaching?
“I should refrain from sexual activity until I can walk 1 mile without stopping.”
“I can have 2.5 g of Sodium each day.”
“I can swallow nitroglycerin pill on the first onset of chest pain.”
“I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”
“I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”
A nurse is caring for a client who has an AV Shunt in his right arm. Which of the following actions should the nurse take?
Check bruit over the shunt on a regular basis
Give IV fluids through the AV Shunt.
Obtain Blood Pressure from the right arm.
Avoid Range-Of-Motion on the right arm
Check bruit over the shunt on a regular basis
A nurse is collecting data from a client who is 12 hour post-op following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?
Oral temperature of 99.7F
Apical Pulse 88/min
Respiratory Rate 20/min
Oxygen Saturation of 90%
Oxygen Saturation of 90%
A nurse is collecting data from a client who is in his third trimester pregnancy, having her routine prenatal visit. The client reports she is dizzy,clammy, and becomes pale lying down. Which of the following actions should the nurse instruct the client to take?
Lie on her left side
Take a brisk walk
Check her temperature
Drink a glass of orange juice
Lie on her left side
A nurse is assisting a client move up in bed. Which of the following action should the nurse take?
Place the bed in the lowest position
Stand with feet together
Ask the client to flex her hips and knees
Raise the head of the bed
Raise the head of the bed
A nurse is reinforcing teaching from a client who has a Urinary Tract Infection and a prescription for antibiotic. Which of the following instructions should the nurse include in teaching?
Take the medication until the manifestations subside
Wear nylon undergarments until manifestations are present
Limit alcohol intake to one beverage per day
Empty bladder every 4 hours.
Empty bladder every 4 hours.
A nurse is performing nasopharyngeal suctioning on an adult client. Which of the following techniques should the nurse use?
Wait one minute between suctioning
Perform inter catheterization of 20cm or 8 inches
Apply intermittent suctioning for 30 seconds
Apply suction while inserting the catheter.
Wait one minute between suctioning
A nurse is caring for a client who has a follow up visit for bipolar disorder and a new prescription for Lithium Therapy. Which of the following indicates Lithium Toxicity?
Urinary retention
Dysrhythmias
Excessive salivation
Hypoglycemia
Dysrhythmias
A nurse is reinforcing teaching for a 36 year old client who is 16 weeks gestation and who is
scheduled for amniocentesis. What is the purpose of amniocentesis?
To determine chromosomal abnormalities
A nurse in a long term care facility has just received change of shift. Which of the following clients should the nurse attend to first?
Client who has a spinal cord injury and needs a dressing change
Client who has a temperature of 101.4 and appears confused
Client who is receiving enteral tube feeding and has a blood glucose of 155 mg/dL
Client who had a hip arthroplasty and is requesting pain medication
Client who has a temperature of 101.4 and appears confused
A nurse is collecting data from a parent of a school age child who is allergic to bee venom. What
should the nurse administer?
Epinephrine (muscle relaxant)
A nurse is caring for a client who has increased ICP following a closed head injury. Which of the following actions should the nurse take?
Place the client in lateral Sim’s position
Monitor the client’s temperature every 4 hours
Wake the client every 6-8 hours
Elevate the Head of the Bed 30 degrees
Elevate the Head of the Bed 30 degrees
A nurse is planning a health promotion program for high school students. Which of the following about cigarette smoking would be the most appropriate to get the students to stop smoking?
Smoking can lead to substance use disorders
Smoking is the no. 1 preventable cause of death
Quitting smoking can help save money for other things
Smoking cause unattractive stain on the teeth and hands
Smoking cause unattractive stain on the teeth and hands
A nurse is preparing to administer intermittent enteral feeding to a client who has a small dour NGT. Which of the following actions should the nurse plan to take?
Chill the formula before administration
Hang the feeding 6 inches above the insertion site
Flush the tubing with 5 mL of water
Elevate the Head of Bed 45 degree
Flush the tubing with 5 mL of water
A nurse is caring for a preschool age child who recently experienced the death of a parent. Which of the following should the nurse expect?
Child curious about funeral service
States everyone dies eventually
States death is punishment for bad behavior.
Recognizes the parent will never wake up
States death is punishment for bad behavior.
A nurse manage is taking measures to increase cost effective. In which of the following client situations should the nurse manager intervene?
An AP dons a mask when providing an oral care to a client who has staphylococcal infection
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
A nurse discards a bottle of saline after it has been opened for 24 hours
An AP is wearing clean gloves when feeding a client who has Hepatitis B
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
A nurse is contributing to the plan of care to a client who has delirium. Which of the following
interventions should the nurse recommend?
Provide the client with four food choices at each meal
Vary the client’s activities daily.
Assist the client to the bathroom every 2 hours.
Assist the client to the bathroom every 2 hours.
A home health nurse is reinforcing teaching with a client about safe food handling to prevent food poisoning. Which of the following instructions should the nurse include in the teaching?
Allow leftover food to cool before refrigerating
Defrost frozen foods in the refrigerator
Set refrigerator to 46.4 degrees
Fahrenheit Cook poultry to 140 degrees Fahrenheit
Allow leftover food to cool before refrigerating
A nurse on a hospice unit is caring for a client that has cancer and is in the active phase of dying. Which of the following findings indicates intervention from the nurse?
Oxygen is in use
Assistive Personnel is encouraging intake of fluids
Benzodiazepines are administered every 4 hours
A family member remains at the client’s bedside for 24 hours
Assistive Personnel is encouraging intake of fluids
A nurse is caring for an adolescent who had a child and is requesting the most reliable method of
birth control. Which of the following should the nurse recommend?
Spermicide
Injectable progesterone
Oral contraceptives
Condoms
Injectable progesterone
A client is collecting nutritional data from a group of adult clients. Which of the following clients
should the nurse recommend an interprofessional conference with a dietitian?
Patient with serum albumin of 4.5
Patient with sodium intake of 1200 mg per day
Patient has a total fat intake 25%
BMI of 32
BMI of 32
A nurse is assisting a client to ambulate when the client begins to have a generalized seizure. What action should the nurse take? (I don’t know the answer for this one)
Place on the side
Supply Oxygen
Oral hygiene
Reorient
Place on the side
A nurse is caring for a client who is 34 weeks gestation. Which of the following statements is the nurse priority to report to the provider?
“Palms of my hands are red and blotchy”
“My heart feels like it skips a beat.”
“Acetaminophen is not working on my persistent headaches”
“I have nosebleeds once a week.”
“Acetaminophen is not working on my persistent headaches”
What is the use/effect of protamine?
Decreasing clotting time
What does it mean when a client is pacing back?
Move the client cards
Client is participating to group therapy
Client returns to the room
Walks to the recreation room
Client returns to the room
What is the adverse effect of the postoperative opioid medication?
Urinary retention
Tachycardia
Diaphoresis
Hypotension
Urinary retention
What is the adverse effect of methylphenidate?
Tachycardia
Ringing of the ears
Metallic taste
Decreased appetite
Decreased appetite
What should be done when the nurse sees a mid-abdominal incision?
Reinforce Dressing
Apply pressure for 30 seconds
Cleanse with normal saline
Notify the provider
Reinforce Dressing
What must be done when the nurse is not sure of calculating the medication dosage
correctly?
Call another nurse to verify the calculation
Recalculate the dosage
Document the incident
Administer the medication
Call another nurse to verify the calculation
What is the adverse effect of Enoxaparin?
Epistaxis
Nausea
Muscle weakness
Hyperglycemia
Epistaxis
What progress must be seen in a four year old child?
Eat vegetables
Familiarize with shapes
Speaking using only 20 to 50
words
Thumb sucking
Eat vegetables
What is the adverse effect of furosemide?
Hypotension
Urinary retention
Fatigue
Hypokalemia
Hypokalemia
What safety measures must be implemented for a 12 month old infant?
Lock the doors and cabinets
Turn pot handles inward
Provide finger foods
Provide a non skid soles
Turn pot handles inward
What action must be done when the nurse finds out that there is a gastric residual prior to
providing bolus feeding?
Notify the provider
Withhold the bolus feeding and check again in an hour
Flush the tube with 240 cc of water
Document the incident
Withhold the bolus feeding and check again in an hour
A nurse is caring for a Asian client who is admitted 2 days ago. Which of the following
practices should the nurse must be mindful of?
Avoid eye contact
Bow
Separate the content of each meals in the tray
Raising the voice
Avoid eye contact
When a nurse is caring for a client who has a terminal cancer, this should be followed strictly.
Treatment times
Isolation precautions
Negative pressure airflow
Advance Directives
Advance Directives
Which of the following tasks the nurse can delegate to the Assistive Personnel to perform?
Catheter care
Dressing change
Fingerstick prior to insulin administration
Performing a head-to-toe assessment
Catheter care
A nurse is caring for a client who is terminally ill, sees the patient’s partner crying and
seemed to be upset. What action should the nurse take?
Ignore the patient’s partner
Encourage the partner to express feelings
Lecture the patient
Call the supervisor
Encourage the partner to express feelings
What should be the action taken when a client is suspected with the manifestations of Bulimia
Nervosa?
Observe the condition and manifestations
Reinforce teaching about proper dietary intake
Notify the provider
Send to the emergency department
Observe the condition and manifestations
The nurse from the morning shift is turning over the reports to the afternoon shift. Which of the following clients must be seen first?
A client who is diagnosed of Guillain-Barre syndrome
A client who has current blood pressure of 165/92 mm Hg
A client who has small laceration on the right thigh
A client who has temperature of 38.5 degrees Celsius
A client who is diagnosed of Guillain-Barre syndrome
Withhold doxycycline if the client is manifesting this symptom.
Crackles
Abdominal distention
Wheezing
Bradycardia
Crackles
What intervention must be implemented for a client who has kidney failure with peripheral
edema?
Decrease water intake
Infuse IV normal saline 0.9%
Ambulate the client to the hallway
Apply antiembolic stockings
Decrease water intake
4 months infant?
Cool mist vaporizer
The LPN/LVN cares for the client after a plaster cast has been applied to the left leg due to a fractured femur. The LPN/ LVN should take which action?
Turn the client every 2 hours
The client has attempted to manage 6 month history of severe joint pain in both knees and
hip joints with over-the-counter-medications. The client states these have not completely resolved the pain. The HCP orders Diclofenac Sodium. When reinforcing teaching about this medication, it is important that the client understands which concern?
Do not take with Aspirin
The family relates having difficulty coping with the emotional outbursts of the family member diagnosed with Alzheimer’s disease. The family members ask the LPN/LVN what they can do about the outbursts. Which response, if made by the LPN/LVN is the best?
Provide a calm, non-chaotic environment
The nursing assistive personnel approaches the LPN/LVN and says, “You need to help my client with morning care because I am not going to be able to get it done.” The LPN/LVN identifies this is an example of which type of delegation?
Reverse delegation
