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A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?
A. Assess for skin necrosis.
B. Educate the family to avoid sharing personal belongings.
C. Administer antitoxin.
D. Ensure the state health department has been notified.
D. Ensure the state health department has been notified.
The client reports experiencing a loss of appetite and shortness of breath within the last month or so. The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is bloated and they have redness of the palms of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per provider’s prescription.
A nurse is caring for a client who has been admitted to the hospital.
Exhibits
Select the 5 actions the nurse should take.
A. Restrict the client’s sodium intake.
B. Provide frequent rest periods for the client.
C. Assess the client’s level of orientation.
D. Instruct the client to avoid blowing their nose forcefully.
E. Place the client on a low-carbohydrate diet.
F. Place the client under contact isolation.
G. Advise the client to avoid the use of soap and alcohol-based lotions.
A. Restrict the client’s sodium intake.
B. Provide frequent rest periods for the client.
C. Assess the client’s level of orientation.
D. Instruct the client to avoid blowing their nose forcefully.
G. Advise the client to avoid the use of soap and alcohol-based lotions.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?
A. Administer an antiemetic medication.
B. Evaluate functioning of the suction device.
C. Replace the NG tube.
D. Provide oral hygiene care.
B. Evaluate functioning of the suction device.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
A. Report the defect to the equipment maintenance staff.
B. Ensure the device inspection sticker is current.
C. Initiate a requisition for a replacement CPM device.
D. Remove the device from the room.
D. Remove the device from the room.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
A. Place sterile gauze over areas of spilled solution within the sterile field.
B. Remove the cap and place it sterile-side up on a clean surface.
C. Hold the bottle in the center of the sterile field when pouring the solution.
D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
C. Hold the bottle in the center of the sterile field when pouring the solution.
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
A. Wear loose-fitting underwear.
B. Void every 5 to 6 hr during the day.
C. Drink four 240 mL (8 oz) glasses of water each day.
D. Take a bubble bath after intercourse.
A. Wear loose-fitting underwear.
A nurse is caring for a newborn.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing _______ and ________.
Options: Hyperglycemia
Bronchopulmonary syndrome
Transient Tachypnea of the Newborn (TTN)
Tachycardia
Bronchopulmonary syndrome
Transient Tachypnea of the Newborn (TTN)
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
A. Pale and a 24-hr fluid deficit of 30 mL
B. Decreased appetite and irritability
C. Temperature 38° C (100.4° F) and pulse rate 124/min
D. Sunken fontanels and dry mucous membranes
D. Sunken fontanels and dry mucous membranes
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
A. Fibromyalgia
B. Fibrocystic breast disease
C. Renal calculi
D. Hypertension.
D. Hypertension.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
A. “I expect this medication to raise my blood pressure.”
B. “I can continue to take St. John’s wort while taking this medication.”
C. “I know it will be a couple of weeks before the medication helps me feel better.”
D. “I should take this medication on an empty stomach.”
C. “I know it will be a couple of weeks before the medication helps me feel better.”
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
A. Place a towel roll under the client’s neck.
B. Align a trochanter wedge between the client’s legs.
C. Position a pillow under the client’s knees.
D. Apply an orthotic to the client’s foot.
D. Apply an orthotic to the client’s foot.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
A. Administer a fluid bolus.
B. Initiate continuous bladder irrigation.
C. Clamp the catheter tubing for 30 min.
D. Obtain a urine specimen for culture and sensitivity.
A. Administer a fluid bolus.
A nurse is reporting a client’s laboratory tests to the provider to obtain a prescription for the client’s daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
A. Platelet count
B. Fibrinogen level
C. INR
D. aPTT
C. INR
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
A. Smacking lips
B. Serpentine limb movement
C. Nonreactive pupils
D. Shuffling gait
D. Shuffling gait
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
A. Recording the client’s progress in the nurses’ notes
B. Having interdisciplinary team meetings for the client on a regular basis
C. Posting swallowing precautions at the head of the client’s bed
D. Noting changes in the treatment plan in the client’s medical record
B. Having interdisciplinary team meetings for the client on a regular basis
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
A. Banana slices
B. Grapes
C. Hot dog
D. Popcorn
A. Banana slices
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
A. Recommend to the provider specific acute care clients for discharge.
B. Determine the medical needs of incoming clients through the emergency department.
C. Act as a liaison between the facility and the media.
D. Call in additional medical-surgical unit nursing care staff.
A. Recommend to the provider specific acute care clients for discharge.
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who received a pain medication 30 min ago for postoperative pain
B. A client who was just given a glass of orange juice for a low blood glucose level
C. A client who has 100 mL of fluid remaining in his IV bag
D. A client who is scheduled for a procedure in 1 hr
B. A client who was just given a glass of orange juice for a low blood glucose level
A nurse is performing postmortem care for a recently deceased client prior to the client’s family visit. Which of the following actions should the nurse plan to take?
A. Cross the client’s arms across their chest.
B. Remove the client’s dentures from their mouth.
C. Place the client in a high-Fowler’s position.
D. Hold the client’s eyes shut for a few seconds.
D. Hold the client’s eyes shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
A. “How long have you been hearing the voices?”
B. “I realize the voices are real to you, but I don’t hear anything.”
C. “What are the voices telling you?”
D. “Have you taken your medication today?”
C. “What are the voices telling you?”
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
A. Decreased inflammation
B. Decreased pain
C. Increased blood pressure
D. Weight loss
D. Weight loss
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A: Don sterile gloves.
B: Turn on the suction and set the pressure.
C: Insert the catheter during the client’s inspiration.
D: Apply suction while rotating the catheter.
E: Rinse the catheter to remove secretions.
B: Turn on the suction and set the pressure.
A: Don sterile gloves.
C: Insert the catheter during the client’s inspiration.
D: Apply suction while rotating the catheter.
E: Rinse the catheter to remove secretions.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
A. Determine if the client’s health care surrogate is aware of the risks and benefits of the procedure.
B. Send the unsigned informed consent form to the facility’s risk manager.
C. Ensure that the client’s family supports the provider’s decision for surgery.
D. Determine if the procedure is medicall
A. Determine if the client’s health care surrogate is aware of the risks and benefits of the procedure.
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
A. “I can infuse the medication at a faster rate.”
B. “I can start the medication 30 minutes earlier.”
C. “I have up to 2 hours after the usual schedule time to give you this medication.”
D. “I can adjust the time and schedule for when it’s convenient for you.”
B. “I can start the medication 30 minutes earlier.”
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
A. Assess the client’s behavior once every hour.
B. Document the client’s behavior prior to being placed in seclusion.
C. Discuss with the client his inappropriate behavior prior to seclusion.
D. Offer fluids every 2 hr.
B. Document the client’s behavior prior to being placed in seclusion.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
A. Submerge the adolescent’s feet in ice water.
B. Initiate seizure precautions.
C. Administer oral acetaminophen.
D. Cover the adolescent with a thermal blanket.
B. Initiate seizure precautions.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
A. “Your name cannot be removed once you are listed on the organ donor list.”
B. “I cannot be a witness for your consent to donate.”
C. “Your desire to be an organ donor must be documented in writing.”
D. “You must be at least 21 years of age to become an organ donor.”
C. “Your desire to be an organ donor must be documented in writing.”
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Assist clients in identifying ways suicide could have been prevented.
B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
C. Discourage clients from sharing negative aspects of their relationship with the deceased persons.
D. Encourage clients to establish a timeline for their own grieving process.
B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?
A. Ask the client to describe her pain.
B. Check the client’s pedal pulse on the right leg.
C. Observe the position of the suspended weight.
D. Remind the client to use the incentive spirometer.
D. Remind the client to use the incentive spirometer.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
A. Negligence
B. Battery
C. Malpractice
D. Assault
D. Assault
A nurse is caring for a client who has been admitted to the antepartum unit.
Exhibits
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
History and Physical
Day 1,0900:
30-year-old client at 33 weeks gestation, Gravida 4 Para 3
Maternal blood type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
Nurses’ Notes
Day 1,0900:
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
Membranes intact.
CBC and urinalysis collected and sent to lab.
30-year-old client at 33 weeks gestation, Gravida 4 Para 3
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
A nurse is caring for a client who has been admitted to the antepartum unit.
History and Physical
Day 1,0900:
30-year-old client at 33 weeks gestation, Gravida 4 Para 3
Maternal blood type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
Nurses’ Notes
Day 1,0900:
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
Membranes intact.
CBC and urinalysis collected and sent to lab.
The nurse should recognize the client is experiencing ________ due to _______.
Preeclampsia ; previous preterm birth
A nurse is caring for a client who has been admitted to the antepartum unit.
History and Physical
Day 1,0900:
30-year-old client at 33 weeks gestation, Gravida 4 Para 3
Maternal blood type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
Nurses’ Notes
Day 1,0900:
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
Membranes intact.
CBC and urinalysis collected and sent to lab.
The client is at risk for developing which of the following 2 complications?
Select 2 complications the client is at risk for developing.
A. Sepsis
B. Placenta previa
C. Disseminated intravascular coagulation
D. Preeclampsia
E. Preterm prelabor rupture of membranes (PROM)
F. Seizures
A. Sepsis
E. Preterm prelabor rupture of membranes (PROM)
A nurse is caring for a client who has been admitted to the antepartum unit.
History and Physical
Day 1,0900:
30-year-old client at 33 weeks gestation, Gravida 4 Para 3
Maternal blood type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
Nurses’ Notes
Day 1,0900:
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
Membranes intact.
CBC and urinalysis collected and sent to lab.
Anticipated vs Unanticipated
A . Administer oxytocin,
B . Administer terbutaline.
C . Administer betamethasone.
D . Maintain bed rest with bathroom privileges.
E . Limit fluid intake to 3,000 mL/day.
F . Place client in supine position.
Anticipated
B . Administer terbutaline.
C . Administer betamethasone.
D . Maintain bed rest with bathroom privileges.
E . Limit fluid intake to 3,000 mL/day.
Unanticipated:
A . Administer oxytocin,
F . Place client in supine position.
Day 1,0930:
Peripheral IV initiated. Provider prescriptions received and implemented.
Day 1, 1000:
Client voided and reports pain and discomfort upon urination. Client states, “I’ve noticed burning when I urinate for the past 2 days.”
The nurse continues to care for the client.
Exhibits
Which of the following actions should the nurse take? Select all that apply.
A. Vaginal culture
B. Obtain provider prescription for antibiotics
C. Ibuprofen 600 mg every 6 hr for mild to moderate pain
D. Obtain provider prescription for phenazopyridine
E. Urine culture
B. Obtain provider prescription for antibiotics
D. Obtain provider prescription for phenazopyridine
E. Urine culture
Day 2, 0800:
Exhibits
Click to highlight the findings that indicate improvement in the client’s condition. To deselect a finding, click on the finding again.
Nurses’ Notes:
Client rates lower back pain a 0 on a scale from 0 to 10.
No reports of vaginal discharge.
Membranes intact
No uterine contractions noted.
FHR baseline 138, minimal variability.
No further reports of burning with urination.
Laboratory Results
WBC 12,000/mm2 (5,000 to 10,000/mm3)
Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Vital Signs
Temperature 37.1° C (98.7° F)
Blood pressure 120/78 mm Hg
Client rates lower back pain a 0 on a scale from 0 to 10.
No reports of vaginal discharge.
No uterine contractions noted.
No further reports of burning with urination.
WBC 12,000/mm2 (5,000 to 10,000/mm3)
Platelet count 188,000/mm3 (150,000 to 400,000/mm3)Temperature 37.1° C (98.7° F)
Blood pressure 120/78 mm Hg
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
A. Wear clean cotton socks every day.
B. Round the edges of toenails when trimming
C. Soak feet twice daily.
D. Use moisturizing lotion between the toes.
A. Wear clean cotton socks every day.
- A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
A. Instruct the client to lift her chin when swallowing.
B. Sit at or below the client’s eye level during feedings.
C. Talk with the client during her feeding.
D. Discourage the client from coughing during feedings.
B. Sit at or below the client’s eye level during feedings.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
A. Hypotension
B. Hematuria
C. Weight loss
D. Polyuria
B. Hematuria
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
A. Fidelity
B. Autonomy
C. Beneficence
D. Veracity
C. Beneficence
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
A. Reassure the child that no one will be told about the abuse.
B. Use leading statements to obtain information from the child.
C. Explain to the child what will happen when the abuse is reported.
D. Ensure that multiple nurses are present for the physical examination.
C. Explain to the child what will happen when the abuse is reported.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
A. Helping clients understand health screenings covered by their insurance plans
B. Educating clients about contraindications to specific immunizations
C. Using an electronic messaging system to remind clients when to take medications
D. Providing clients with information about the benefits of exercise
C. Using an electronic messaging system to remind clients when to take medications
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
A. “You don’t have to go through with the treatment.”
B. “Your doctor wouldn’t have ordered this treatment unless it was necessary.”
C. “It’s okay to be nervous before this treatment.”
D. “Most people who have this procedure feel better following the treatment.”
A. “You don’t have to go through with the treatment.”
A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
A. “After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.”
B. “My baby should always start on the same breast when feeding.”
C. “The more my baby is at the breast sucking, the more milk I will produce.”
D. “Manually expressing my milk will decrease my milk supply.”
C. “The more my baby is at the breast sucking, the more milk I will produce.”
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
A. Reposition the client without the use of assistive devices.
B. Discuss the client’s preferences for determining a repositioning schedule.
C. Evaluate the client’s ability to help with repositioning.
D. Raise the side rails on both sides of the client’s bed during
C. Evaluate the client’s ability to help with repositioning.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
A. “I can go jogging after 2 weeks.”
B. “I can resume activities, such as sewing,”
C. “I should bend at the waist when putting on my shoes.”
D. “I can lift objects that are less than 10 pounds.”
D. “I can lift objects that are less than 10 pounds.”
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
A. Speak slowly when talking to the interpreter.
B. Speak directly to the client.
C. Pause in the middle of sentences.
D. Use gestures to convey meaning.
B. Speak directly to the client.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium
B. Aspirin
C. Acetaminophen
D. Ibuprofen
C. Acetaminophen
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
B. A client who has epidural analgesia and weakness in the lower extremities.
C. A client who has a hip fracture and a new onset of tachypnea.
D. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%).
C. A client who has a hip fracture and a new onset of tachypnea.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?
A. Shoulders
B. Area of trauma
C. Palms of the hands
D. Sacrum
C. Palm of hands
A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
A. Experiencing delusions
B. A history of being in prison
C. Previous violent behavior
D. Male gender
C. Previous violent behavior
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
A. Temperature 37.4° C (99.3° F)
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Contractions lasting 80 seconds
B. FHR baseline 170/min
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
A. Digoxin 0.25 mg PO daily
B. Cimetidine PO twice daily
C. Epoetin alfa 150 units/kg three times weekly
D. Tetracycline 200 mg PO
A. Digoxin 0.25 mg PO daily
lient tearfully agreed to be admitted to the mental health unit. Day 2 1000:
Client states, “I feel a bit better. I get these thoughts sometimes when I am stressed. Smoking sometimes helps, but not yesterday. I have not been sleeping well.”
Client reports recent job loss and concern about having money for food. Reports first episode at age 19 as a freshman in college, which lasted for a few days. After several episodes, they dropped out of school. Client states, “My parent told me they had episodes like this years ago and were glad I didn’t have brain problems too. But maybe I do.”
A nurse is caring for a client in an emergency department.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress
Actions to Take:
Engage with the client several times each day to establish trust
Reduce external stimuli
Potential Condition:
Brief psychotic disorder
Parameters to Monitor:
Suicide risk
Temperature
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
A. A client who is ambulatory and receiving oxygen
B. A client who is bedridden and wears a hearing aid
C. A client who has a fracture and is in balance suspension traction
D. A client who uses a wheelchair and is confused
A. A client who is ambulatory and receiving oxygen
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
A. Refute the client’s delusions using logic.
B. Give the client one simple direction at a time.
C. Establish eye contact when communicating with the client.
D. Allow the client to choose among a variety of activities each day.
E. Reinforce orientation to time, place, and person.
B. Give the client one simple direction at a time.
C. Establish eye contact when communicating with the client.
E. Reinforce orientation to time, place, and person.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
A. How to secure the tracheostomy tube with ties at the back of the neck
B. How to change the tracheostomy dressing using clean technique
C. How to operate the portable suction machine
D. How to change the non-disposable tracheostomy tube daily
C. How to operate the portable suction machine
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
A. Provide humidification of the room air.
B. Suggest rinsing his mouth with an alcohol-based mouth wash.
C. Instruct the client on the use of esophageal speech.
D. Offer the client saltine crackers between meals.
A. Provide humidification of the room air.
A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?
A. Provide anticipatory guidance classes to parents through public schools.
B. Have a nurse from outside the community provide health lectures at the county hospital.
C. Encourage rural residents to focus health spending on tertiary health interventions.
D. Launch a media campaign to increase awareness about industrial pollution.
A. Provide anticipatory guidance classes to parents through public schools.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
A. Tinnitus
B. Rhinorrhea
C. Malaise
D. Drooling
C. Malaise
A nurse in an emergency department is caring for a client
Click the highlight findings that require follow-up
Client presents for evaluation of severe pain and upper abdomen that radiates into his back. States pain began approximately 12 hours ago and is worse when he has supine or after he eats. Rates pain 7 to 10 skill. Sclera noted to be yellow. Heart rate regular, lungs clear to oscillation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports his last bowel movement was yesterday. Denies recent illnesses, takes no prescribe medication’s. Client is alert and oriented X4.
Client presents for evaluation of severe pain and upper abdomen that radiates into his back.
States pain began approximately 12 hours ago and is worse when he has supine or after he eats.
Rates pain 7 to 10 skill.
Sclera noted to be yellow.
Abdomen firm, bowel sounds hypoactive.
Client guards abdomen and grimaces during palpation.
A nurse in an emergency department is caring for a client
H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting…….Consumed 3 to 4 alcohol drinks per day……
For each finding, click to specify if the finding is consistent with pancreatitis or peritonitis
Hyperbilirubinemia
Bloody stools
Abdominal pain
Elevated WBC count
Pancreatitis:
Hyperbilirubinemia
Abdominal pain
Elevated WBC count
Peritonitis:
Bloody stools
Abdominal pain
Elevated WBC count
A nurse in an emergency department is caring for a client
H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting…….Consumed 3 to 4 alcohol drinks per day……
The nurse should first address the clients _____ followed by the clients___
Lung sounds ; BP
A nurse in an emergency department is caring for a client
H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting…….Consumed 3 to 4 alcohol drinks per day……
The nurse is preparing to notify the provider about the client’s current condition, for each potential provider prescriptions click to specify if the prescription is anticipated or contraindicated for the client
- administer famotidine 20 MG via intermittent IV infusion twice daily
- administer lactated ringers 1 L via IV bolus
- insert a nasal gastric tube and maintain low intermittent suction
- insert an indwelling urinary catheter
Anticipated:
- administer famotidine 20 MG via intermittent IV infusion twice daily
- administer lactated ringers 1 L via IV bolus
- insert a nasal gastric tube and maintain low intermittent suction
Contraindicated:
- insert an indwelling urinary catheter
A nurse in an emergency department is caring for a client
H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting…….Consumed 3 to 4 alcohol drinks per day……
The nurse is providing teaching to the client about self-care. Select 3 statements the nurse should include in the teaching
a. notify your provider if you experience, vomiting or diarrhea
b. limit alcohol intake to no more than one drink per day
c. you should eat foods that are low and fat
d. you can drink beverages that contain caffeine
e. you should eat food and protein
a. notify your provider if you experience, vomiting or diarrhea
c. you should eat foods that are low and fat
e. you should eat food and protein
nurse in an emergency department is caring for a client
H&P 0400: 57 year old male client presents to the severe abdominal and epigastric pain that began about 12 hr ago. Pain 7/10, reports pain worsens after eating and radiates into his back. Nauseous and has had several episodes of vomiting…….Consumed 3 to 4 alcohol drinks per day……
The nurse is preparing to discharge the client. Which of the following statement by the client indicate an understanding of the discharge teaching? SATA
A. I will eat small frequent meals
B. I should expect my bowel movements to be pale in color
C. I will limit my morning to no more than 2 cups
D. I will notify my provider if my urine is dark
E. I will eat fish for dinner at least twice per week
A. I will eat small frequent meals
B. I should expect my bowel movements to be pale in color
E. I will eat fish for dinner at least twice per week
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
A. Instruct the client to avoid coughing during the procedure.
B. Place the client in the prone position during the procedure.
C. Position the client on the affected side for 4 hr following the procedure.
D. Inform the client that he will be NPO for 6 hr prior to the procedure.
A. Instruct the client to avoid coughing during the procedure.
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
A. Palpable fontanels
B. Natural loss of deciduous teeth
C. Nontender, protruding abdomen
D. Head circumference exceeds chest circumference
C. Nontender, protruding abdomen
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
A. Attach the restraint to the bed’s side rails.
B. Document the client’s condition every 15 min.
C. Request a PRN restraint prescription for clients who are aggressive.
D. Remove the client’s restraint every 4 hr.
B. Document the client’s condition every 15 min.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
A. “There was a total of 10 sponges used during the procedure.”
B. “The client is a member of the board of directors.”
C. “The client was intubated without complications.”
D. “The estimated blood loss was 250 milliliters.”
D. “The estimated blood loss was 250 milliliters.”
A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?
A. Prepare the client for an MRI of the brain.
B. Insert an indwelling urinary catheter for the client.
C. Determine the client’s Glasgow Coma Scale score.
D. Administer mannitol IV bolus to the client.
C. Determine the client’s Glasgow Coma Scale score.
A nurse in an emergency department is caring for a client following a motor vehicle crash. The client’s Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?
A. The client withdraws from pain.
B. The client opens eyes to sound.
C. The client is unable to obey commands.
D. The client is oriented times three.
D. The client is oriented times three.
A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
A. First-degree atrioventricular block
B. Complete heart block
C. Premature atrial complexes
D. Atrial fibrillation
A. First-degree atrioventricular block
A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?
A. Hypertension
B. Primary glaucoma
C. Osteoarthritis
D. Amputation
A. Hypertension
0900:
Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 Ib) in 3 months.
0930:
Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted.
A nurse is caring for a client.
Exhibits
For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn’s disease. Each finding may support more than 1 disease process.
Fever
Steatorrhea
Anemia
Weight loss
Diarrhea
Ulcerative Colitis:
Fever
Anemia
Weight loss
Diarrhea
Diverticulitis:
Fever
Anemia
Diarrhea
Crohn’s:
ALL
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
A. “If there are therapies available to you, your provider will tell you about them.”
B. “We can review some information to help you select a safe alternative practitioner.”
C. “I’m sure you can find alternative remedies through an online support group.”
D. “Feel free to try whatever therapies that fit within your personal belief system.”
B. “We can review some information to help you select a safe alternative practitioner.”
A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?
A. Sit in a chair next to the bed.
B. Sit on the bed next to the client.
C. Stand at the side of the bed.
D. Stand at the foot of the bed.
A. Sit in a chair next to the bed.
A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?
A. Bulging fontanels
B. Hypertonicity
C. Bradycardia
D. Acrocyanosis
B. Hypertonicity
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse, but a new bag is not readily available. Which of the following actions should the nurse take?
A. Administer dextrose 10% in water.
B. Temporarily discontinue the infusion.
C. Slow the TPN infusion rate.
D. Give 500 mL of lactated Ringer’s solution.
A. Administer dextrose 10% in water.
A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Right upper quadrant
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
A. “The immunization for varicella should be given at least 1 month prior to delivery.”
B. “The hepatitis B immunization should not be obtained until after you finish breastfeeding.”
C. “You can receive the immunization for influenza at any time during your pregnancy.”
D. “You can receive the rubella immunization during the third trimester of pregnancy.”
C. “You can receive the immunization for influenza at any time during your pregnancy.”
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
A. Clean the equipment with an alcohol-based cleaning product.
B. Apply petroleum jelly to soothe the mucous membranes.
C. Avoid using nail polish remover around the client.
D. Use synthetic fabrics for the client’s bedding.
C. Avoid using nail polish remover around the client.
A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?
A. Place tongue on the mouthpiece of the meter.
B. Blow into the meter as hard and quickly as possible.
C. Maintain a semi-Fowler’s position during testing
D. Record the average of the readings.
B. Blow into the meter as hard and quickly as possible.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
A. Loperamide 4 mg PO
B. Bisacodyl 10 mg rectal suppository
C. Magnesium hydroxide 30 mL PO
D. Famotidine 20 mg PO
C. Magnesium hydroxide 30 mL PO
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?
A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.”
B. “Administer pancreatic enzymes on an empty stomach.”
C. “Restrict intake of foods that contain gluten.”
D. “Perform chest percussion and postural drainage at least twice daily.”
D. “Perform chest percussion and postural drainage at least twice daily.”
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
A. Administer a cathartic suppository 30 min prior to scheduled defecation times.
B. Increase the amount of refined grains in the client’s diet.
C. Provide the client with a cold drink prior to defecation.
D. Encourage a maximum fluid intake of 1,500 mL per day.
A. Administer a cathartic suppository 30 min prior to scheduled defecation times.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
A. A noncoring needle
B. An angiocatheter
C. A butterfly needle
D. A 25-gauge needle
A. A noncoring needle
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
A. Report of discomfort at the insertion site
B. Bounding pulses in the affected extremity
C. Heart rate 90/min
D. Hematoma over the insertion site
D. Hematoma over the insertion site
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
A. Pulse rate 100/min
B. 1+ proteinuria via urine dipstick
C. Deep tendon reflexes 2+
D. Urine output 20 mL/hr
C. Deep tendon reflexes 2+
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
A. Engage the panic alarm.
B. Tell the client, “You seem to be very upset.”
C. Use a face shield with a mask when providing care to the client.
D. Initiate seclusion protocol.
B. Tell the client, “You seem to be very upset.”
0900:
Client reports, “I’m bloated and my stomach hurts.” History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history. Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
A nurse is caring for a client who is admitted to the medical-surgical unit.
Exhibits
The nurse reviews the client’s laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.
A. Current medications
B. Hemoglobin and hematocrit
C. Stool results
D. WBC count
E. Blood pressure
F. Temperature
G. Respiratory rate
H. Heart rate
A. Current medications
B. Hemoglobin and hematocrit
C. Stool results
E. Blood pressure
H. Heart rate
0900:
Client reports, “I’m bloated and my stomach hurts.” History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history. Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
The nurse anticipates the client will likely require ______ as evidenced by the client’s ______.
Endoscopy ; stool results
0900:
Client reports, “I’m bloated and my stomach hurts.” History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history. Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
The nurse should first anticipate the ______ and then _______
Obtain IV access ; prepare to administer IV fluids
0900:
Client reports, “I’m bloated and my stomach hurts.” History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history. Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
A. Insert a large-bore IV catheter.
B. Witness the client signing a consent for transfusion.
C. Flush the transfusion tubing with dextrose 5% in water.
D. Explain to the client that transfusion reactions are not serious.
E. Have a second nurse confirm the information on the blood label.
A. Insert a large-bore IV catheter.
B. Witness the client signing a consent for transfusion.
E. Have a second nurse confirm the information on the blood label.
0900:
Client reports, “I’m bloated and my stomach hurts.” History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, “It’s a burning sensation that radiates to my back. I think I’ve lost a little weight too.” Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history. Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
Indicated vs not indicated
A . Stay with the client for the first 15 min of the transfusion.
B . Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg.
C . Obtain the first unit of packed RBCs from the blood bank.
D . Start an IV bolus of lactated Ringer’s solution.
E . Document the blood product transfusion in the client’s medical record.
Indicated:
A . Stay with the client for the first 15 min of the transfusion.
C . Obtain the first unit of packed RBCs from the blood bank.
E . Document the blood product transfusion in the client’s medical record.
Not indicated:
B . Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg.
D . Start an IV bolus of lactated Ringer’s solution.
The nurse is assessing the client following the transfusion of 2 units of packed RBCs.
Click to highlight the findings that indicate improvement in the client’s condition. To deselect a finding, click on the finding again.
Laboratory Results
1800:
WBC count 6,700/mm3 (5,000 to 10,000/mm3)
Hemoglobin 12 g/dL (14 to 18 g/dL)
Hematocrit 36% (40% to 52%)
Vital Signs
1800:
Blood pressure 112/74 mm Hg
Heart rate 95/min
Respiratory rate 18/min
Temperature 37.5°C (99.5° F)
Oxygen saturation 100% via 2 L/min nasal cannula
Assessment
1800:
Physical Exam:
General: no distress
HEENT: oropharynx clear, mucous membranes moist and pink
Respiratory: bilateral breath sounds clear
Gl: epigastric tenderness to palpation, no rebound tenderness or guarding Neuro: awake and alert
Hemoglobin 12 g/dL (14 to 18 g/dL)
Hematocrit 36% (40% to 52%)
Blood pressure 112/74 mm Hg
Heart rate 95/min
General: no distress
HEENT: oropharynx clear, mucous membranes moist and pink
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?
A. Uterine tenderness
B. Polyhydramnios
C. Nausea
D. Spotting
D. Spotting
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses should the nurse make?
A. “I don’t think you will benefit from reviewing your therapist’s notes right now.”
B. “We can provide a copy of your records, but the therapist’s notes are not included.”
C. “Are you not happy with your treatment?”
D. “Why are you interested in seeing your therapist’s notes?”
B. “We can provide a copy of your records, but the therapist’s notes are not included.”
A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
A. The nurse should use a filter needle to withdraw the medication.
B. The nurse should break the neck of the ampule toward their body.
C. The nurse should dispose of the ampule in the trash can.
D. The nurse should use the same needle to draw up and inject the client.
A. The nurse should use a filter needle to withdraw the medication.
A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
A. Hypertension
B. Herpes zoster
C. Obesity
D. Hypothyroidism
B. Herpes zoster
A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?
A. “We can initiate medical care until you get legal assistance in preparing your advance directives.”
B. “A social worker will assist you to find affordable legal representation.”
C. “Advance directives can be signed without legal representation.”
D. “Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.”
C. “Advance directives can be signed without legal representation.”
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
A. Elevate the client’s arm prior to insertion.
B. Apply a tourniquet below the venipuncture site.
C. Select a site on the client’s dominant arm.
D. Choose a vein that is palpable and straight.
D. Choose a vein that is palpable and straight.
A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?
A. “Do you have thoughts of harming yourself?”
B. “How do you manage your behavior?”
C. “Do you have a criminal record?”
D. “How do you get along with your peers at school?”
A. “Do you have thoughts of harming yourself?”
A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?
A. Sedation
B. Bradypnea
C. Euphoria
D. Constipation
Bradypnea
A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?
A. Take on an empty stomach.
B. Schedule dosage at bedtime.
C. Increase dietary calcium.
D. Monitor for weight loss.
C. Increase dietary calcium.
A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?
A. Check the client for a sulfa allergy.
B. Instruct the client to notify the provider if diarrhea develops.
C. Infuse the medication over 10 min.
D. Refrigerate the medication after reconstitution.
B. Instruct the client to notify the provider if diarrhea develops.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
A. Offer small amounts of clear liquids 6 hr following surgery.
B. Administer analgesics on a scheduled basis for the first 24 hr.
C. Apply a warm compress to the operative site once daily.
D. Give cromolyn nebulized solution every 8 hr.
B. Administer analgesics on a scheduled basis for the first 24 hr.
A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?
A. The leader lectures about medication adverse effects to the group members.
B. The leader encourages group members to remain silent until questions are called for.
C. The leader has group members vote on what they would like to learn about during the session.
D. The leader allows the group to discuss whatever they would like to regarding their medications.
D. The leader allows the group to discuss whatever they would like to regarding their medications.
A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
B. Place the client in a side-lying position prior to assessing the fetal heart rate.
C. Measure the fundal height to determine the placement of the ultrasound stethoscope.
D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?
A. “I should keep the medication in the original container.”
B. “I can crush the medication and mix with applesauce.”
C. “I should replace any unused medication every 6 months.”
D. “I can store the medication in the refrigerator.”
A. “I should keep the medication in the original container.”
A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?
A. Ask each nurse to take turns making the assignments.
B. Tell the nurses that the assignments will be more equitable in the future.
C. Encourage collaboration between the two nurses when making the assignments.
D. Arrange for the nurses to have as few shifts together as possible.
C. Encourage collaboration between the two nurses when making the assignments.
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
A. Confirm that the client is able to urinate.
B. Compare the client’s current weight with preprocedure weight.
C. Examine for leakage at the site of the procedure.
D. Check the client’s serum albumin levels.
B. Compare the client’s current weight with preprocedure weight.
A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion?
A. Decreased Hgb
B. Increased platelets
C. Increased Hct
D. Decreased WBC count
C. Increased Hct
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?
A. A client who is scheduled for a colonoscopy and is taking sodium phosphate.
B. A client who received a Mantoux test 48 hr ago and has an induration.
C. A client who is taking bumetanide and reports an increase in urinary frequency.
D. A client who is taking warfarin and has started to breastfeed.
D. A client who is taking warfarin and has started to breastfeed.
A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
A. Advance the catheter into the vein.
B. Release the tourniquet.
C. Retract the stylet.
A. Advance the catheter into the vein.
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
A. “Use an incentive spirometer every 4 hours.”
B. “Remain on bed rest for 24 hours following the procedure.”
C. “Participate in range-of-motion exercises.”
D. “Place a pillow under your knees while in bed.”
C. “Participate in range-of-motion exercises.”
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?
A. Drink 1.5 L of fluids each day.
B. Increase exercise activity.
C. Take mineral oil at bedtime.
D. Decrease insoluble fiber intake.
B. Increase exercise activity.
A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching?
A. Take a hot shower in the morning to decrease stiffness.
B. Apply cold packs directly on the skin of the affected joints.
C. Administer biological response modifiers to prevent infection.
D. Cluster physical activities during the day.
A. Take a hot shower in the morning to decrease stiffness.
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?
A. Placing a yellow bracelet on a client who is at risk for falls.
B. Administering potassium via IV bolus.
C. Leaving a nasogastric tube clamped after administering oral medication.
D. Documenting communication with a provider in the progress notes of the client’s medical record.
B. Administering potassium via IV bolus.
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?
A. Positioning both hands on the grips with his elbows slightly flexed
B. Moving both crutches with the stronger leg forward first
C. Supporting his body weight while leaning on the axillary crutch pads
D. Stepping with his affected leg first when going up stairs
A. Positioning both hands on the grips with his elbows slightly flexed
A nurse in an emergency department is caring for a client. Nurses’ Notes.
1200:.
Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.
1210:.
Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client’s adult child answers most questions. Client grimacing and guarding right arm.
Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.
1230:.
Client’s adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.
Vital Signs. 1200:.
Temperature 36.7° C (98° F). Heart rate 96/min.
Blood pressure 142/96 mm Hg. Respiratory rate 16/min.
SpO2 97% on room air.
Click to highlight the findings the nurse should report to the provider
Client noted to have several superficial abrasions on right forearm and elbow.
Has numerous bruises in various stages of healing on arms and upper chest
Client rates pain in right lower forearm an 5 on a 0 to 10 pain scale and is not moving arm
BP: 142/96
A nurse is an ER caring for a client
Nurses notes: Client is an 82 year old male who presents with his adult child for evaluation of right arm pain after a fall, Noted to have several superficial abrasions on right forearm and elbow, also has numerous bruises in various stages of healing on arms and upper chest. 1210: Client noted to keep head down and makes limited eye contact. speaks very softly and looks at adult child before answering……………
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect or financial maltreatment.
Client reports having little food in house: Neglect, financial
Client has bruises various stages: Physical maltreatment
Client wears dirty clothes: Neglect
Client has no access to bank acct: Financial maltreatment
A nurse is an ER caring for a client
Nurses notes: Client is an 82 year old male who presents with his adult child for evaluation of right arm pain after a fall, Noted to have several superficial abrasions on right forearm and elbow, also has numerous bruises in various stages of healing on arms and upper chest. 1210: Client noted to keep head down and makes limited eye contact. speaks very softly and looks at adult child before answering……………
The nurse should first address the clients ________ and ________
Safety ; pain
A nurse in an emergency department is caring for a client. Nurses’ Notes.
Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.
1210:
Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client’s adult child answers most questions. Client grimacing and guarding right arm.
Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.
1230:.
Client’s adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.
Select the 5 findings the nurse should plan to include in the report
A. ECG results.
B. Client’s report of lack of food in home.
C. client’s report of lack of access to bank accounts.
D. Clients avoidance of eye contact.
E. Clients report of weight loss.
F. Numerous bruises in various stages of healing.
B. Client’s report of lack of food in home.
C. client’s report of lack of access to bank accounts.
D. Clients avoidance of eye contact.
E. Clients report of weight loss.
F. Numerous bruises in various stages of healing.
A nurse is an ER caring for a client
Diagnostic results:
1215: ECG Normal sinus rhythm 1250: Xray right arm: FX of right radius
Click to highlight the findings that require immediate follow-up
Respiratory:
Respiratory rate 11/min
SpO2 94 on room air
Lungs clear to auscultation
Musculoskeletal:
Reports pain worsening in right forearm
States right hand is tingly
Able to move fingers
Respiratory rate 11/min
SpO2 94 on room air
Reports pain worsening in right forearm
States right hand is tingly
A nurse in an emergency department is caring for a client.
Diagnostic Results.
1215:.
ECG: Normal sinus rhythm. 1250:.
X-ray, right arm: Fracture of right radius.
A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement?
Select all that apply.
A. The client has gained 1.8 kg (4 lb). BMI is 18.9.
B. The clients adult child prepares two meals per day for the client.
C. The clients clothing is clean and appropriate for the weather.
D. The client receives three baths per week from a home care aide.
E. The client reports frequent toothaches and lack of dental care.
F. The client makes eye contact and smiles when speaking.
A. The client has gained 1.8 kg (4 lb). BMI is 18.9.
B. The clients adult child prepares two meals per day for the client.
C. The clients clothing is clean and appropriate for the weather.
D. The client receives three baths per week from a home care aide.
F. The client makes eye contact and smiles when speaking.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
A. “I should wash my hands for 10 seconds with hot water after working in the garden.
B. “I can clean my cat’s litter box during my pregnancy.”
C. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
D. “I should take antibiotics when I have a virus.”
C. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Implement firm but flexible boundaries in their relationship.
B. Minimize open discussion regarding the changes to avoid embarrassment.
C. Decrease socialization with extended relatives until roles are identified.
D. Encourage authoritative communication from the adult child.
A. Implement firm but flexible boundaries in their relationship.
A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?
A. Crusting of exudate on the incisional line
B. Mild swelling under the sutures near the incisional line
C. Pink-tinged coloration on the Incisional line
D. Partial separation of the upper part of the incisional line
D. Partial separation of the upper part of the incisional line
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
A. Creatinine clearance
B. Potassium level
C. Platelet count
D. Prealbumin
C. Platelet count
A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?
A. Canned black beans
B. Red meat
C. Fish
D. Cheese
C. Fish
A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?
A. Hip arthroplasty 1 week ago
B. Acute renal failure 6 months ago
C. Chronic obstructive pulmonary disease
D. Family history of malignant hypertension
A. Hip arthroplasty 1 week ago
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take?
A. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
C. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
D. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?
A. Measure gastric residual volumes every 4 hr.
B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication.
C. Advance the rate of the feeding every 2 hr.
D. Maintain the head of the bed at a 20” angle.
A. Measure gastric residual volumes every 4 hr.
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?
A. Meet with providers to discuss measures to decrease the infections.
B. Schedule nursing staff training for infection control procedures.
C. Identify possible precipitating factors related to the infections.
D. Revise the current policy for catheter care.
C. Identify possible precipitating factors related to the infections.
Day 1
0800:
Client reports increasing pain in their right knee and left wrist over the last 2 years.
A nurse in an outpatient clinic is caring for a client.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Actions to Take:
- Instruct the client to apply heat and cold
- Instruct the client to apply topical analgesics.
Condition Most Likely Experiencing:
Osteoarthritis
Parameters to Monitor:
- ESR
- Joint deformities
A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?
A. Perform a sterile dressing change for a client who has an abdominal wound.
B. Perform an admission assessment for a client who is scheduled for surgery.
C. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
A. Perform a sterile dressing change for a client who has an abdominal wound.
A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?
A. Limit oral feedings to 30 min in length.
B. Weigh the infant every other day.
C. Place the infant in the prone position for naps.
D. Check the infant’s oxygen saturation every 6 hr.
A. Limit oral feedings to 30 min in length.
A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. Include any adverse effects of the medications the client might develop.
B. Compare new prescriptions with the list of medications the client reports.
C. Exclude nutritional supplements from the list of medications the client reports.
D. Encourage the client to make his own list after he returns to his home.
B. Compare new prescriptions with the list of medications the client reports.
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
A. Applies suction for 15 seconds
B. Encourages the client to cough during suctioning
C. Waits for 2 min between suctions
D. Inserts the catheter without applying suction
B. Encourages the client to cough during suctioning
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
A. Use droplet precautions when caring for the child.
B. Administer aspirin to the child for fever.
C. Assign the child to a negative air pressure room.
D. Assess the child for Koplik spots.
C. Assign the child to a negative air pressure room.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A. A client who is 1 day postoperative following a vertebroplasty.
B. A client who has cancer and a sealed implant for radiation therapy.
C. A client who has COPD and a respiratory rate of 44/min.
D. A client who is receiving heparin for deep vein thrombosis.
A. A client who is 1 day postoperative following a vertebroplasty.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
A. Faintness upon rising
B. Bleeding gums
C. Swelling of the face
D. Urinary frequency
C. Swelling of the face
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
A. Maternal hypoglycemia
B. Chorioamnionitis
C. Maternal fever
D. Fetal anemia
A. Maternal hypoglycemia
A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client’s food tray?
A. Shrimp salad and tomato soup with milk
B. Scrambled eggs and toast with milk
C. Ham sandwich with milk
D. Bacon and cheese quiche with milk
B. Scrambled eggs and toast with milk
A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?
A. “I should not use my affected hand for 4 to 6 weeks.”
B. “I can apply heat for the first 24 hours to minimize the pain in my hand.”
C. “I should expect numbness and tingling in my hand.”
D. “I will need to keep my hand elevated above my heart for several days.”
D. “I will need to keep my hand elevated above my heart for several days.”
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
A. Continuously monitor the child’s respiratory status.
B. Carefully suction the child’s oropharynx to remove secretions.
C. Assess the child for frequent swallowing.
D. Administer pancreatic enzymes with meals.
A. Continuously monitor the child’s respiratory status.
A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?
A. Epistaxis
B. Dizziness
C. Shortness of breath
D. Headache
B. Dizziness
A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?
A. Use the balloon port to obtain the sterile specimen.
B. Disconnect the catheter from the collection tubing.
C. Unclamp the collection port below the bag.
D. Obtain the specimen from the retention port.
D. Obtain the specimen from the retention port.
A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
A. Insert a pillow under the client’s knees.
B. Assist the client into the lithotomy position.
C. Position the client in reverse Trendelenburg
D. Place a wedge under one of the client’s hips.
D. Place a wedge under one of the client’s hips.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
A. Frequent nosebleeds
B. Upper extremity hypotension
C. Increased intracranial pressure
D. Weak femoral pulses
D. Weak femoral pulses
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
A. Vomiting
B. Epigastric pain
C. Contractions
D. Hypertension
C. Contractions
A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?
A. “A nurse will draw blood from your baby’s inner elbow.”
B. “Your baby will be given 2 ounces of water to drink prior to the test.”
C. “This test should be performed after your baby is 24 hours old.”
D. “This test will be repeated when your baby is 2 months old.”
C. “This test should be performed after your baby is 24 hours old.”
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
A. Maintain eye contact with the newborn during feedings.
B. Minimize noise in the newborn’s environment.
C. Swaddle the newborn with his legs extended.
D. Administer naloxone to the newborn.
B. Minimize noise in the newborn’s environment.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
A. Perform the procedure prior to meals.
B. Hold hand flat to perform percussions on the child.
C. Perform the procedure twice each day.
D. Administer a bronchodilator after the procedure.
A. Perform the procedure prior to meals.
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
A. “The child usually has an aura prior to onset.”
B. “This type of seizure lasts 30 to 60 seconds.”
C. “This type of seizure has a gradual onset.”
D. “This type of seizure can be mistaken for daydreaming”
D. “This type of seizure can be mistaken for daydreaming”
A charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system. Which of the following information should the nurse include?
A. “You will be given access to the medical records of every client in the facility.”
B. “You will be asked to change your password once per year.
C. “Information Technology will install a firewall to secure client information.”
D. “Documentation of sensitive material is performed by the charge nurse.”
C. “Information Technology will install a firewall to secure client information.”
A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?
A. Evaluate the client for orthostatic hypotension.
B. Monitor the client’s urine output.
C. Obtain the client’s laboratory results.
D. Check the client for nasal congestion.
A. Evaluate the client for orthostatic hypotension.
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?
A. Refer the adolescent to a local mental health clinic.
B. Contact the adolescent’s parent for assistance.
C. Advise the adolescent to place the newborn for adoption.
D. Assist the adolescent in applying for Medicaid.
D. Assist the adolescent in applying for Medicaid.
Client is receiving chemotherapy for treatment of colon cancer
A nurse is caring for a client.
Exhibits
A nurse is reviewing the client’s electronic medical record. Which of the following findings require follow up? Select all that apply.
A. Breath sounds
B. Potassium level
C. Blood pressure
D. WBC count
E. Temperature
A. Breath sounds
C. Blood pressure
D. WBC count
E. Temperature
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
A. Monitor for the development of Koplik spots.
B. Administer aspirin to the client.
C. Initiate airborne precautions.
D. Isolate the client from staff who are pregnant.
D. Isolate the client from staff who are pregnant.
Postoperative day 2
0900:
Client reports history of deep vein thrombosis (DVT) after cholecystectomy 15 years ago.
Client reports pain of 5 on a scale of 0 to 10 at perineal surgical incision site and bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.
Reports hard, painful bowel movement on postoperative day 1.
Client transferring out of bed to chair independently. Extremities cool and dry with 2+ peripheral pulses.
1300:
Client reports abdominal cramping and small, hard, painful bowel movement after lunch. Ambulating independently in hallway. Reports pain of 8 on a scale of 0 to 10 in perineum.
A nurse is caring for a postoperative client following a perineal prostatectomy.
Exhibits
For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
A . Apply warm compresses to the incision site.
B . Administer enema to relieve constipation.
C . Irrigate indwelling urinary catheter with 50 mL of normal saline.
D . Place a blanket roll under the client’s knees while in bed.
E . Maintain bed rest for 2 days postoperatively.
Anticipated:
A . Apply warm compresses to the incision site.
C . Irrigate indwelling urinary catheter with 50 mL of normal saline.
Contraindicated:
B . Administer enema to relieve constipation.
D . Place a blanket roll under the client’s knees while in bed.
E . Maintain bed rest for 2 days postoperatively.
Day 1
1400:
Client has paraplegia and reports, “I have had a cough the last few days. I haven’t had an appetite either.” Denies nausea, vomiting, or diarrhea. Alert and oriented to person, place, and time. Skin is intact. Vital signs stable.
Day 2
1830:
Client is experiencing tachycardia, productive cough, and confusion.
A nurse is caring for a client in an acute care setting.
Exhibits
Complete the following sentence by using the list of options.
The client is at risk for _____ as evidenced by the client’s _______.
hypostatic pneumonia ; immobility
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?
A. Frequent swallowing
B. Increased drowsiness
C. Elevated pain level
D. Diminished breath sounds
A. Frequent swallowing
A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?
A. Supervise return demonstration of diaphragm use.
B. Document the client’s level of understanding about potential adverse effects.
C. Teach the client how to insert the diaphragm.
D. Determine the client’s knowledge about diaphragm use.
D. Determine the client’s knowledge about diaphragm use.
A nurse is caring for a 75-year-old client who is admitted to the medical- surgical unit.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Actions to Take:
- Check for pedal pulses and signs of ischemia
- Request a prescription for a lower-extremity Doppler flow study.
Potential Conditions:
Deep vein thrombosis
Parameters to Monitor:
- PT/INR
- bleeding
G1P1, spontaneous vaginal delivery with median episiotomy at 39 weeks of gestation. Newborn 4,508 g (9 lb 15 oz). APGARs: 8 at 1 min, 9 at 5 min.
The client is at highest risk for developing Select… evidenced by the client’s Select… Group B streptococcus B-hemolytic: positive (negative)
Received 2 doses of intravenous penicillin G while in labor.
A nurse is caring for a postpartum client in an outpatient setting.
Visible crack noted on left nipple
Exhibits
Complete the following sentence by using the lists of options.
The client is at highest risk for developing ________ as evidenced by the client _____.
Mastitis
Cracked nipple
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Encourage the client to watch television.
B. Sit with the client to provide a sense of security.
C. Administer a dose of atomoxetine to decrease anxiety.
D. Teach the client how to meditate.
B. Sit with the client to provide a sense of security.
58-year-old client reporting chest pain is admitted to the emergency department. Client states chest pain began this morning after breakfast and chest pain radiates to left arm. Client rates chest pain as 4 on a scale of 0 to 10. Client has medical history of hypertension, type 2 diabetes mellitus, and hyperlipidemia.
Social history: denies alcohol use, has smoked a pack of cigarettes per day for 35 years Current medications:
Lisinopril 20 mg PO daily Glucophage 500 mg PO BID Simvastatin 40 mg PO daily
A nurse is caring for a client.
Exhibits
Complete the following sentence by using the list of options.
After notifying the provider, the nurse should first ______ and then ________
administer oxygen at 2 L/min via nasal cannula
administer sublingual nitroglycerin
1 week ago:
Client reports that manifestations of hopelessness and disinterest are lessened, but present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to clinic in 1 week.
2 weeks ago:
Client with a history of generalized anxiety disorder and major depressive disorder. Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week.
A nurse is caring for a client at a clinic.
Exhibits
Complete the following sentence by using the lists of options.
The client is at risk for developing ______ due to ______.
Serotonin syndrome ; adverse effects of paroxetine
A nurse is caring for a client in the medical-surgical unit.
Exhibits
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.
A. Review the need for the indwelling urinary catheter daily.
B. Encourage the client to drink 3000 mL of fluid daily.
C. Place the drainage bag on the bed when transporting the client.
D. Empty the drainage bag when it is half-full.
E. Change the indwelling urinary catheter tubing every 3 days.
F. Use soap and water to provide perineal care.
A. Review the need for the indwelling urinary catheter daily.
B. Encourage the client to drink 3000 mL of fluid daily.
F. Use soap and water to provide perineal care.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
A. “I can give you information about respite care if you are interested.”
B. “I am sure you’re doing a great job taking care of your mother.”
C. “You should consider taking a sleeping pill before bed each night.”
D. “It is always difficult caring for someone who is terminally ill.”
A. “I can give you information about respite care if you are interested.”
0600:
Temperature 37.2° C (99° F)
Heart rate 66/min
Respiratory rate 16/min
BP 130/82 mm Hg
Pulse oximetry 96% on room air
1000:
Temperature 37.6° C (99.7° F)
Heart rate 70/min
Respiratory rate 20/min
BP 160/102 mm Hg
Pulse oximetry 96% on room air
Client reports pain as 10 on a scale of 0 to 10 from headache.
A nurse is caring for a client who has a spinal cord injury.
Exhibits
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
A . Perform suctioning
B . Withhold pain medication for headache until other manifestations resolve.
C . Assess blood pressure every 15 min.
D . Administer nifedipine.
E . Assess for urinary retention.
F . Place client in supine position.
Anticipated:
C . Assess blood pressure every 15 min.
D . Administer nifedipine.
E . Assess for urinary retention.
Contraindicated:
A . Perform suctioning
B . Withhold pain medication for headache until other manifestations resolve.
F . Place client in supine position.
A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
A. Apply the largest cuff available.
B. Use the palpatory method to determine blood pressure.
C. Place the arm above the level of the client’s heart.
D. Deflate the cuff quickly.
B. Use the palpatory method to determine blood pressure.
1330:
Temperature 36.8° C (98.2° F)
Heart rate 88/min
Respiratory rate 16/min
BP 110/64 mm Hg
Oxygen saturation 96% on oxygen 3 L/min via simple face mask
1345:
Temperature 37° C (98.6° F)
Heart rate 112/min
Respiratory rate 20/min
BP 108/60 mm Hg
Oxygen saturation 94% on oxygen 3 L/min via simple face mask
1400:
Temperature 38.3° C (101° F)
Heart rate 152/min
Respiratory rate 26/min
BP 90/54 mm Hg
A nurse is caring for a client who is postoperative following a right hip arthroplasty.
Exhibits
For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process.
Hypercapnia
Muscle rigidity
Tachycardia
Urticaria
Wheezes
Malignant Hyperthermia:
Hypercapnia
Muscle rigidity
Tachycardia
Wheezes
Latex allergy:
Tachycardia
Urticaria
Wheezes
Hypovolemic shock:
Hypercapnia
Muscle rigidity
Tachycardia
A nurse is caring for an older adult client.
Exhibits
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
General
Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, “My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.”
Physical
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up “once or twice per night to go to the bathroom.” Client reports not wanting to eat anymore. Client’s child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect
Client says, “Why don’t you just leave me? I am of no use.”
I found the title to the car today, signed over to me.”
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.
Client reports not wanting to eat anymore.
Client’s child reports their parent has lost about 8 lb in the past month.
Client says, “Why don’t you just leave me? I am of no use.”
A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?
A. “Do you need a prescription for an antianxiety medication?”
B. “Do you need information on hospice care?”
C. “Would you like to talk to a counselor about advance directives?”
D. “Would you like to speak to a spiritual advisor?”
D. “Would you like to speak to a spiritual advisor?”
A nurse is caring for a client in a clinic.
Exhibits
Based on the information in the client’s medical record, which of the following findings require immediate follow-up?
Select the 4 findings that require follow-up.
A. Smoking marijuana to clear their mind
B. BP 122/80 mm Hg
C. Witnessing their family’s death
D. Attends school regularly
E. Client experiences nightmares
F. Startles easy during thunderstorm
G. Heart rate 99/min
H. Caregiver reporting client acting differently than usual
A. Smoking marijuana to clear their mind
C. Witnessing their family’s death
E. Client experiences nightmares
H. Caregiver reporting client acting differently than usual
1000:
Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client’s parents were called. They contacted the primary care provider, who arranged for a direct admission.
Weight 37.2 kg (82 lb)
Height 157.5 cm (62 inches) BMI 15
1200:
Client observed during noon meal. Client pushed food around the plate. Intake 10% of meal. Offered nutritional supplement. Client declined. Reports feeling anxious due to admission and mealtime. Client states, “I cannot eat this with you watching me.”
1500:
Snack provided. Client observed throwing snack into the trash can. When realized they had been observed, they admitted to their action and asked for a second snack. Client ate 10% of the snack.
A nurse is caring for a recently admitted 18-year-old client.
Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Actions to Take:
- Focus on the clients underlying feelings of dysphoria and lack of control
- Provide a structure meal environment
Potential Condition:
Anorexia nervosa
Parameters to Monitor:
- Cardiac function with ECG
- Weight on a daily basis
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client’s cur- rent IV infusion and the information received during the shift report.Which of the following actions should the nurse take?
A. Contact the charge nurse to see if the prescription was changed
B. complete an incident report and place it in the client’s medical record
C. submit a written warning for the nurse involved in
D. check the expiration date on safety inspection sticker of the pump
A. Contact the charge nurse to see if the prescription was changed
A nurse is caring for a client who is near the end of life and is on a complete bed rest. The client states that he needs to have a bowel movement.The nurse offers a bed pan. The client states “I’ve always used the bathroom”. Which of the following responses should the nurse make?
A. Tell me what concerns you have about using a bedpan
B. make sure to use a nearby furniture to support yourself when walking to the bathroom
C. I will have the physical therapist ambulate you to the bathroom
D. you have to use the bedpan for your own safety
A. Tell me what concerns you have about using a bedpan
A nurse is caring for a client who is in labor. Prolapsed umbilical cord
Select the five actions the nurse should take. SATA
A. Increase the flow rate of the maintenance IV fluid
B. have the charge nurse notify the provider
C. place the client in a Trendelenburg position
D. exert upward pressure on the presenting part
E. attempt to push the umbilical cord back into the cervix
F. administer oxygen at 10L/min via non rebreather face mask
A. Increase the flow rate of the maintenance IV fluid
B. have the charge nurse notify the provider
C. place the client in a Trendelenburg position
D. exert upward pressure on the presenting part
F. administer oxygen at 10L/min via non rebreather face mask
A nurse is caring for a client who is 4 days postpartum following a cesarean birth.
For each potential assessment finding, click to spec- ify if the finding is consistent with mastitis or endometritis.
Assessment Findings:
Foul-smelling lochia
Painful, tender breasts
Temperature
Chills
Mastitis:
Painful tender breasts
Temperature
Chills
Endometritis:
Foul-smelling lochia
Temperature
A nurse is assessing a client who has a possible right pneumothorax. Which of the following findings should the nurse expect?
a. Reduced right sided breath sounds
b. intercostal retractions
c. High pitched stridor
d. paradoxical chest movement
a. Reduced right sided breath sounds
Which of the following interventions should the nurse include in the plan of care? Select all that apply
a. increase oxygen flow rate to 4L/min
b. assess the clients breath sounds
c. perform chest percussions and vibration
d. Restrict the clients fluid intake
e. instruct the client to perform diaphragmatic breath- ing
f. place the client in a supine position
a. increase oxygen flow rate to 4L/min
b. assess the clients breath sounds
c. perform chest percussions and vibration
e. instruct the client to perform diaphragmatic breath- ing
A nurse is caring for a client who is postoperative following a liver biopsy. Which of the following positions should the nurse place the client immediately following the procedure?
a. Prone
b. Trendelenburg
c. high fowlers
d. right lateral
d. right lateral
A nurse is caring for a client who states he recently purchase lavender oil to use when he gets the flu.The nurse should recognize which of the following findings as a potential contraindication for using lavender?
a. The client has a history of alcohol use disorder
b. the client has a history of asthma
c. the client takes vitamin C daily
d. the client takes furosemide twice daily
b. the client has a history of asthma
A nurse is providing discharge teaching to a client fol- lowing a total gastrectomy. The nurse should instruct the client about which of the following medications?
a. Ranitidine
b. vitamin B12
c. vitamin K
d. metoclopramide
b. vitamin B12
A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?
a. Take your temperature immediately after waking and before getting out of bed
b. take your temperature within 30 minutes after your first morning void
c. take your temperature one hour after getting out of bed
d. take your temperature every night before going to bed
a. Take your temperature immediately after waking and before getting out of bed
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hours ago. Which of the following findings indicates a positive test?
a. An induration measuring 10mm
b. an induration measuring 5mm
c. A reddened area measuring 10mm
d. A reddened area measuring 5mm
a. An induration measuring 10mm
A nurse is caring for a client who has heart failure. Which of the following manifestation should the nurse expect?
a. Crackles in the lungs
b. decreased thirst
c. tachycardia
d. poor skin turgor
a. Crackles in the lungs
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
a. Encouraged the client to avoid wearing shoes at home
b. place a throw rug over electrical cords
c. mark the edges of the doorway to the house with tape
d. ensure that area rugs have rubber backs
d. ensure that area rugs have rubber backs
A nurse is assessing a client who received hydromor- phone 4 milligrams IV 15 minutes ago. The client has a respiratory rate of 10/min.The nurse should prepare to administer which of the following medications?
a. Acetylcysteine
b. Protamine
c. naloxone
d. flumazenil
c. naloxone
A nurse came for a client whose child died from can- cer. The client states it’s hard to go on without him. Which of the following questions should the nurse ask the client first?
a. What has helped you through difficult times in the past
b. has anyone in your family committed suicide
c. is there anyone you would like involved in your care
d. are you thinking about ending your life
d. are you thinking about ending your life
A nurse is teaching a client about advanced direc- tives. Which of the following statements by the client indicates an understanding of the teaching?
a. A living will is a document that includes my wishes about health care decisions
b. my provider will make my healthcare decisions if I complete advanced directives
c. advanced directives outline who inherits my mate- rial possessions in the event of my death
d. my partner needs to be present as a witness when I sign a living will
a. A living will is a document that includes my wishes about health care decisions
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
a. Swelling on the face
b. bleeding gums
c. urinary frequency
d. faintness upon rising
a. Swelling on the face
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
a. Weight gain
b. dry mouth
c. sedation
d. shuffling gait
d. shuffling gait
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total par- enteral nutrition (TPN). Which of the following state- ments by the newly licensed nurse indicates an un- derstanding of the procedure?
a. I will hang a new bag of TPN and IV tubing every 24 hours
b. I will obtain the client’s weight every other day
c. I will monitor the client’s blood glucose level every eight hours
d. I will increase the rate of the TPN infusion to ensure the correct amount is given
a. I will hang a new bag of TPN and IV tubing every 24 hours
A nurse is assessing a client who has histrionic per- sonality disorder. Which of the following manifesta- tion should the nurse expect?
a. Suspicious of others
b. self-centered behavior
c. violates others rights
d. callousness
b. self-centered behavior
A nurse in an emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
a. Prepare to assist with intubation
b. obtain a throat culture
c. suction to child’s oropharynx
d. prepare a cool mist tent
a. Prepare to assist with intubation
A nurse came for a client who is pregnant.The nurse is reviewing the client’s medical record. Select 5 findings that indicate a potential prenatal complication.
a. Urine protein
b. fetal activity
c. blood pressure
d. urine ketones
e. respiratory rate
f. report of a headache
g. gravida/parity
b. fetal activity
c. blood pressure
e. respiratory rate
f. report of a headache
g. gravida/parity
The nurse is continuing care for the client.
The nurse is initiating the client’s plan of care. Which of the following interventions should the nurse implement? SATA
a. Provide a low stimulation environment
b. maintain bed rest
c. give anti hypertensive medication
d. monitor intake and output hourly
e. administer betamethasone
f. Obtain a 24 hour urine specimen
g. perform a vaginal examination every 12 hours
a. Provide a low stimulation environment
b. maintain bed rest
c. give anti hypertensive medication
e. administer betamethasone
f. Obtain a 24 hour urine specimen
he nurse is continuing care for the client.
Complete the following sentence by using the list of options.
The provider has admitted the client to the inpatient obstetrics and written prescriptions based on the client’s condition.
The action the nurse should take first is _____________ followed by ________________.
Evaluating the fetal heart rate tracing
Inserting an indwelling urinary catheter.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the clients to increase in her diet to prevent a neural tube defect?
a. Calcium
b. zinc
c. Iron
d. Folate
d. Folate
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is a priority for the nurse to report to the provider?
a. Tachycardia
b. dry cough
c. Dyspnea
d. Hypotension
c. Dyspnea
A nurse is performing a neurological examination on a client as a part of a complete physical assessment. The nurse should identify the cranial nerve XI is in- tact when the client performs which of the following actions?
a. Shrugs his shoulders
b. sticks his tongue out
c. frowns symmetrically
d. identifies as our taste
a. Shrugs his shoulders
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
a. Avoid preparing medications for more than two clients at one time
b. complete and incident report if a client vomits after taking a medication
c. inform the client about the action of each medica- tion prior to administration
d. Read medication labels at least twice prior to ad- ministration
a. Avoid preparing medications for more than two clients at one time
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistant personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
a. Delegate tasks to the APP
b. determine goals of the day
c. develop an hourly time frame for tasks
d. schedule daily activities
b. determine goals of the day
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
a. Perform the cleansing procedure with a swab 2 times
b. pick up the catheter 13 cm (5 in) from its tip
c. cleanse the tip of the penis in a side to side motion
d. lift the penis so that it is perpendicular to the client’s body
d. lift the penis so that it is perpendicular to the client’s body
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
a. Monitor blood pressure every two hours
b. attach an inline filter to the IV tubing
c. protect the IV bag from exposure to light
d. keep calcium gluconate at the clients bedside
b. attach an inline filter to the IV tubing
A nurse is speaking with a caregiver of a client who has Alzheimer’s disease. The caregiver states, “providing constant care is very stressful and it is affecting all areas of my life”. Which of the following actions should the nurse take?
a. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client
b. recommend allowing the client to have time alone in their room throughout the day
c. discuss methods of how to communicate with the client about resolving problem behaviors
d. assist the caregiver to arrange for a daycare pro- gram for the client
d. assist the caregiver to arrange for a daycare pro- gram for the client
A nurse and an assistant personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
a. A client who requests assistance to use the bedside commode
b. A client who has a prescription for compression stockings and did not receive them
c. a client who requests to sit in the bedside chair while watching TV
d. a client who consumes all the food from their meal tray
b. A client who has a prescription for compression stockings and did not receive them
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the clients nutritional requirements?
a. Maintain calorie intake at 1500 per day
b. provide a low protein, high carbohydrate diet
c. make a calorie count for foods and beverages
d. schedule meals at six hour intervals
c. make a calorie count for foods and beverages
A nurse is caring for a client who is receiving radia- tion therapy and it’s experiencing anorexia. Which of the following actions should the nurse take?
a. Encouraged the client to drink low protein supplements
b. tell the client to drink two glasses of water with meals
c. serve the clients largest meal in the evening
d. provide the client with cold foods rather than hot foods
d. provide the client with cold foods rather than hot foods
A nurse is teaching dietary guidelines to a client who has celiac disease.Which of the following food choices is appropriate for this client?
a. Wheat crackers
b. canned barley soup
c. potato pancakes
d. white flour tortillas
c. potato pancakes
A nurse is collecting a sputum specimen for a client who has tuberculosis. Which of the following actions should the nurse take?
a. Wait one day to collect the specimen if the client cannot provide sputum
b. where’s sterile gloves to collect the specimen from the client
c. ask the client to provide 15 to 20 ML of sputum into the container
d. obtain the specimen immediately upon the client waking up
d. obtain the specimen immediately upon the client waking up
A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibril- lator. Which of the following information should the nurse include?
a. Expect to have a rapid pulse rate for the first few weeks
b. Wear loose fitting clothing
c. return in two weeks for a follow up MRI
d. resume tub baths and swimming after 24 hours
b. Wear loose fitting clothing
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
a. Place the clients head of bed flat
b. apply heat to the client’s abdomen
c. keep the client on NPO status
d. administer A laxative to the client
c. keep the client on NPO status
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following action should the nurse take first?
a. Refer the family to a grief support group
b. determine the roles of individual family members
c. encourage the family to assign specific task to individual family members
d. assist the family to establish a daily routine
b. determine the roles of individual family members
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine.Which of the followiing laboratory values should the nurse monitor?
a. Liver function test
b. kidney function test
c. hemoglobin and hematocrit
d. serum sodium and potassium
a. Liver function test
A home health nurse is planning care for a client who has Alzheimer’s disease. Which of the following actions should the nurse include in the plan of care?
a. Replace the carpet with hardwood floors
b. encourage physical activity prior to bedtime
c. wear clothing with zippers instead of buttons
d. place the locks at the tops of exterior doors
d. place the locks at the tops of exterior doors
A nurse came for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
a. Discard the radioactive source in the client’s trash can
b. place the client soiled bed linen in a biohazard bag outside the client’s room
c. wear an isolation gown when caring for the client
d. keep visitors at least six feet (1.8m) away from client
d. keep visitors at least six feet (1.8m) away from client
A nurse enters our clients room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right. Placing them in the order of performance. Use all the steps)
RACE
- transport the client to another area of the nursing unit
- use the units fire extinguisher to attempt to put out the fire
- Activate the facilities fire alarm system
- Close all nearby windows and doors
- transport the client to another area of the nursing unit
- Activate the facilities fire alarm system
- Close all nearby windows and doors
- use the units fire extinguisher to attempt to put out the fire
A nurse is discussing discharge plans with an old- er adult client who lives alone and has left sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
a. Reviewing information about support groups for individuals who have had a stroke
b. obtaining an alert system to get help in case of a fall
c. providing information about available transportation resources
d. choosing an agency to provide home physical therapy
b. obtaining an alert system to get help in case of a fall
The nurse is assessing the client. Select the four findings that require immediate follow up.
EXHIBIT 1
A 52 year old client brought to the emergency de- partment by adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to the client’s adult child. Client exhibits constant movements and poor concentration here in clothing are unclean appears to be listening to unseen others skin turgor poor.
Select the 4 findings that require immediate follow-up.
a. hallucinations
b. heart rate
c. sleep pattern
d. skin turgor
e. hygiene
a. hallucinations
b. heart rate
d. skin turgor
e. hygiene
The nurse continues to care for the client.
Which assessment findings are consistent with psychosis or mania?
hallucinations
disorganized thought process
pressured speech
lack of sleep
excessive spending habits
Psychosis:
hallucinations
disorganized thought process
lack of sleep
Mania:
hallucinations
pressured speech
lack of sleep
excessive spending habits
The nurse continues to care for the client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is most likely experiencing ________ as evidenced by the clients __________.
Psych
Mania ; Euphoric mood
The nurse continues care for the client.
A nurse on the inpatient mental health unit is plan- ning care for the client. For each potential provider’s prescription, click to specify if the prescription is anticipated or contraindicated for the client.
Potential prescriptions:
encourage to avoid napping during the day
place client in room away from nurse station
weigh client each day
provide client with high calorie fluids every hour
ANTICIPATED:
encourage the client to avoid napping during the day
provide client with high calorie fluids every hour
CONTRAINDICATED:
place client in room away from nurse station
weigh client each day
The nurse is continuing care for the client.
The nurse is providing teaching about lithium to the client and clients adult child. Select three statements the nurse should include. SATA
a. Blurred vision is an expected adverse effect of this medication
b. it will take at least a week before this medication reaches a therapeutic level
c. this medication can cause nausea and drowsiness
d. you will be placed on a low sodium diet while taking this medication
e. this medication can cause weight gain
a. Blurred vision is an expected adverse effect of this medication
b. it will take at least a week before this medication reaches a therapeutic level
c. this medication can cause nausea and drowsiness
The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client’s condition? SATA
a. The client engages in quiet activities in their room
b. the client slept 5 hours the previous night
c. the client consumes 8 ounces of high calorie fluids each hour
d. the client takes 2 short naps during the day
e. the client appears to listen to unseen others
a. The client engages in quiet activities in their room
b. the client slept 5 hours the previous night
c. the client consumes 8 ounces of high calorie fluids each hour
A nurse in a family health clinic is caring for a client who requires information regarding the correct use of condoms. Which of the following statements should the nurse make?
a. Use of a petroleum based lubricant with a condom increases the condoms effectiveness
b. condoms are equally effective for birth control with or without the use of vaginal spermicides
c. when using implanted contraceptive methods condoms should also be used to protect against STD’s
d. ensure that the condom fits snugly over the tip of the penis
c. when using implanted contraceptive methods condoms should also be used to protect against STD’s
A nurse is assessing the fontanelles of an 8 month old infant. Which of the following findings should the nurse recognize as an expected finding?
a. Both fontanelles are the same size
b. both fontanelles show molding
c. the posterior fontanelle is open
d. the anterior fontanelle is open
d. the anterior fontanelle is open
A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?
a. Rectal
b. Tympanic
c. Axillary
d. Oral
c. Axillary
A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority?
a. Dysphagia
b. excoriation of the skin in the neck and chest
c. xerostomia
d. client reports a pain level of six on a scale from zero to 10
a. Dysphagia
A nurse is assessing a client who has type one diabetes mellitus and was administered insulin lispro one hour ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
a. Hot dry skin
b. acetone breath
c. confusion
d. polydipsia
c. confusion
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
a. Take pancrelipase
b. complete oral hygiene
c. eat a meal
d. using an albuterol inhaler
d. using an albuterol inhaler
A nurse is working with a client who has an anxiety disorder and is in orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
a. We should discuss resources to implement in your daily life
b. let me show you simple relaxation exercise to man- age stress
c. we should establish our rules in the initial session
d. let’s talk about how you can change your response to stress
c. we should establish our rules in the initial session
A nurse manager is planning a staff in service to address advocacy and client care. The nurse should promote which of the following practices during the in service? Select all that apply.
a. Encouraging clients to seek further information from the provider
b. honoring family requests to withhold medical infor- mation
c. addressing client needs when providing resources
d. making decisions about health care on clients behalf
e. promoting health care access
a. Encouraging clients to seek further information from the provider
c. addressing client needs when providing resources
e. promoting health care access
A nurse is implementing seizure precaution for a client who has had a clonic tonic seizure. Which of the following intervention should the nurse include in the plan of care?
a. Provided tracheostomy tray at the beds
b. place the client in supine position
c. insert an IV saline lock
d. A plastic tongue depressor at the client’s bedside
c. insert an IV saline lock
A nurse is caring for a male who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care?
a. Wash the penis from the scrotum to the tip using a spiral motion
b. use water with no soap to prevent skin irritation
c. discard the washcloth after cleansing the urethral meatus
d. don’t sterile gloves to prevent infection
a. Wash the penis from the scrotum to the tip using a spiral motion
A nurse is reviewing the medical history of a client who asks about the use of warfarin.The nurse should identify which of the following findings as a con- traindication for the administration of this medication?
a. Recent myocardial infarction
b. recent eye surgery
c. breast cancer
d. thrombophlebitis
b. recent eye surgery
A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?
a. Administer nitroglycerin 0.4mg SL 30 minutes before the procedure
b. draw blood specimens for culture and sensitivity
c. obtain a CBC with differential
d. transport the client to radiology for a CT scan
c. obtain a CBC with differential
A nurse is caring for a client who has a new diagno- sis of chlamydia trachomatis. Which of the following actions should the nurse take?
a. Report the infection to the state Department of Health
b. administers attracts the phone via intermittent IV bolus
c. schedule the client for retesting in one week
d. instruct the client to abstain from sexual intercourse for one month
a. Report the infection to the state Department of Health
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
a. A client who has narcissistic personality disorder and is mocking others during group therapy
b. a client who has obsessive compulsive disorder and is upset about a change in daily routine
c. a client who has depressive disorder and requires assistance with ADL’s
d. a client who is taking clozapine to treat schizophrenia and reports a sore throat
d. a client who is taking clozapine to treat schizophrenia and reports a sore throat
A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?
a. I’m so glad I’ve retired because the work was making me sick and depressed
b. since I retired I have entered many gardening competitions
c. there were layoffs on my company so I journaled about what I accomplished during my career
d. I had to retire because my boss didn’t like me
c. there were layoffs on my company so I journaled about what I accomplished during my career
A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
a. Obtain a prescription for pain medication
b. collect blood cultures
c. transport the child to obtain a CT scan
d. initiate seizure precautions
d. initiate seizure precautions
A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?
a.There is a loop of tubing below the drainage system
b. the system is working properly
c. the tubing is partially obstructed by clots
d. the lung has re expanded
b. the system is working properly
A nurse is teaching a group of school aged children about healthy snack options. Which of the following snacks should the nurse include?
a. Cheesecake
b. air popped popcorn
c. milkshake made with whole milk
d. baked potato chips
b. air popped popcorn
A nurse is teaching a client who is pregnant and has genital herpes simplex virus HSV. Which of the following statements should the nurse include in the teaching?
a.You will need to have a cesarean birth if there are any visible lesions
b. you can apply a cortisone cream to the lesions twice each day
c. you should take 600 milligrams of ibuprofen every eight hours for discomfort during an outbreak
d. your baby’s cord blood will be tested to determine if she has contracted HSV
a.You will need to have a cesarean birth if there are any visible lesions
A nurse is caring for a 9 year old child at a clinic.
The nurse reviews the assessment findings.
The nurse should determine that which of the follow- ing findings are consistent with a sprain, a fracture, or a dislocation?
edema
ecchymosis
pain level
sensation
Sprain:
edema
pain level
sensation
Fracture:
edema
ecchymosis
pain level
Dislocation:
edema
pain level
sensation
The nurse is continuing care for the child.
Complete the following sentence by using the lists of options.
Swelling
The client is at a highest risk for developing _________ as evidenced by the child’s ___________.
Compartment syndrome ; Paresthesia
The nurse is continuing to care for the child. Drag words from the choices below the fill in each blank in the following sentence.
The nurse should anticipate a prescription for ______________ and _____________.
Surgical consultation
Pain medication
The nurse is continuing care for this child. Select 3 priority action the nurse should take.
a. Review cast care instructions with the child’s par- ents
b. administer ibuprofen 200 milligrams PO
c. place a non adherent dressing on the right knee abrasion
d. explain the cast application procedure to the child
e. apply ice packs to the fingers and along the right forearm
f. elevate the affected form with pillow
a. Review cast care instructions with the child’s par- ents
b. administer ibuprofen 200 milligrams PO
f. elevate the affected form with pillow
A nurse is caring for a client who has a stool cul- ture that is positive for Clostridium difficile. Which of the following infection control precaution should the nurse take?
a. Place a mask on the client prior to transport
b. wear a face shield prior to entering the clients room
c. use an alcohol based rub following client care
d. remove the protective gown while in the client’s room
d. remove the protective gown while in the client’s room
A nurse is providing preoperative teaching to a client about the administration of morphine via PCA pump. Which of the following statements by the client indi- cates an understanding of the teaching?
a. Using this machine increases my risk of overdose
b. I can get pain medication anytime as long as I press the button
c. my partner can press my pain medication button for me if I am sleeping
d. I will receive a limited amount of pain medication when I press the button
d. I will receive a limited amount of pain medication when I press the button
A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring.The cardiac rhythm strip shows a wavy baseline, not distin- guishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?
a. Second degree heart block
b. sinus tachycardia
c. Ventricular asystole
d. atrial fibrillation
d. atrial fibrillation
A nurse is preparing to administer the first dose of sulfasalazine via intermittent infusion to a client. Which of the following actions should the nurse take first?
A. Check the compatibility of surface line with the clients existing IV fluids
b. review the clients allergy history
c. assess the IV for patency
d. obtain the reconstituted antibiotic from the pharmacy
b. review the clients allergy history
A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?
a. Increased blood pressure
b. swollen area on calf
c. urinary frequency
d. decreased serum calcium level
b. swollen area on calf
A nurse is preparing to administer 3 medications to a client who is receiving continuous enteral feeding through an Ng tube. Which of the following actions is appropriate for the nurse to take?
a. Flush the Ng tube with 5 mL of water
b. use a syringe to allow the medication to flow by gravity
c. add medication directly to enteral feeding
d. dissolve the medications together
b. use a syringe to allow the medication to flow by gravity
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following instructions should the nurse include in the teaching?
a. Soak in a warm bath everyday
b. take an oral estrogen supplement
c. drink 2 liters of water per day
d. empty your bladder every six hours
d. empty your bladder every six hours
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
a. Position the client’s knee slightly higher than the hips when up in a chair
b. raise the head of the client’s bed to a high fowler’s position
c. elevate the clients affected leg on a pillow when in bed
d. keep an abduction pillow between the clients legs
d. keep an abduction pillow between the clients legs
A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?
a. Monitor vital signs every hour for the first 4 hours
b. observe for bruising of the skin
c. administer medications intramuscularly
d. provide a diet low in protein
b. observe for bruising of the skin
A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following action should the nurse take?
a. Have the client store smaller tanks under his bed
b. ensure that the client checks the gauge weekly
c. place the oxygen tank away from curtains and drapes
d. store the oxygen tank wrench in a locked cabinet
c. place the oxygen tank away from curtains and drapes
The nurse manager is addressing reports of conflict within a nursing unit.The nurse should identify which of the following situations as an example of interpersonal conflict?
a. A nurse experiences insulting comments directed at them by another nurse
b. a nurse expresses concern that another shift works fewer holiday hours
c. a nurse has a personal difficulty with caring for clients who have HIV
d. a nurse submits a complaint about another depart- ment’s handoff reporting
a. A nurse experiences insulting comments directed at them by another nurse
A school nurse is performing scoliosis screenings. the nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
a. Uneven shoulder and pelvic heights
b. limited range of motion of the hips
c. mild pain in the hip region
d. exaggerated curvature of the sacrum
a. Uneven shoulder and pelvic heights
A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery. Which of the following actions should the nurse take to pro- mote learning?
a. Speak loudly when addressing the client
b. connect new information with the client’s past experiences
c. present the information to the client using abstract concepts
d. use the 12 point font when printing written materials for the client
b. connect new information with the client’s past experiences
A nurse in a long term care facility is admitting a client who has dementia. Which the following actions should the nurse take to reduce their risk for client injury?
a. Place the bedside table at the foot of the bed
b. raise the side rails up when the client is in bed
c. keep the television on during the night
d. assist the client to the toilet frequently
d. assist the client to the toilet frequently
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?
a. A client who received a mantoux test 48 hours ago and has an induration
b. a client who is scheduled for a colonoscopy and is taking sodium phosphate
c. a client who is taking warfarin and has an INR of 1.8
d. a client who is taking bumetanide and has a potassium level of 3.6 mEq/L
c. a client who is taking warfarin and has an INR of 1.8
A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago.The nurse notes pink tinged urine in the drainage bag. Which of the following action should the nurse take?
a. Warm the irrigation solution
b. maintain the irrigation solution rate
c. replace the indwelling urinary catheter
d. perform the crede’s maneuver
b. maintain the irrigation solution rate
A charge nurse on a medical surgical unit is assist- ing with the emergency response plan following an external disaster in the community. In the anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge?
a. A client who is receiving heparin for deep vein thrombosis
b. a client who has COPD and respiratory rate of 44/min
c. a client who has cancer and a sealed implant for radiation therapy
d. A client who is one day postoperative following a vertebroplasty
d. A client who is one day postoperative following a vertebroplasty
A nurse is caring for a client who has pneumonia and tells the nurse, it feels like an elephant is sitting on my chest. The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?
a. Serum potassium
b. 12 lead ECG
c. chest X-ray
d. PT and INR
b. 12 lead ECG
A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
a. Pain on inhalation
b. Bradycardia
c. Stridor
d. friction rub
a. Pain on inhalation
A nurse in an antempartum unit is caring for a client.
Specify which assessment findings are consistent with chorioamnionitis or preeclampsia.
elevated uric acid level
blurred vision
decreased platelet count
purulent amniotic fluid
fever
chorioamnionitis:
elevated uric acid level
decreased platelet count
purulent amniotic fluid
fever
preeclampsia:
fever
blurred vision
Complete the following sentence by using the list of options.
Patient in labor
The nurse should first notify the provider about ________ followed by _________.
Fetal station and presentation
The frequency of uterine contractions
A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medication should the nurse identify as being incompatible with warfarin?
a. Propranolol
b. lisinopril
c. magnesium hydroxide
d. naproxen
d. naproxen
A charged nurse is teaching a newly licensed nurse to provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?
a. Battery
b. Negligence
c. libel
d. Assault
d. Assault
A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?
a. Baseline FHR 115/min
b. three uterine contractions within 10 minutes
c. prolonged decelerations
d. moderate variability in the FHR
c. prolonged decelerations
A nurse is planning care for a client who is scheduled to receive a transfusion of packed red blood cells. Which of the following actions should the nurse plan to take?
a. Store the unit of blood at room temperature for one hour prior to the transfusion
b. obtain venous access using a 22 gauge needle
c. use a solution of 0.9% sodium chloride to flush the transfusion tubing
d. ensure that the transfusion is completed within six hours
c. use a solution of 0.9% sodium chloride to flush the transfusion tubing
A nurse in an emergency department is assessing a client who reports ingesting 30 diazepam tablets 20 minutes ago. The client is lethargic and has a respiratory rate of 10/min . After securing the client’s airway and initiating an IV, which of the following actions should the nurse take next?
a. Monitor the client’s IV site for thrombophlebitis
b. initiate seizure precautions for the client
c. evaluate the client for further suicidal behavior
d. administer flumazenil to the client
d. administer flumazenil to the client
A nurse is assessing a client following an EGD. Which of the following findings should the nurse report to the provider?
a. Belching
b. sore throat
c. flatulence
d. abdominal pain
d. abdominal pain
A nurse is reviewing the medication administration record of a client. Which of the following prescriptions should the nurse clarify?
a. Acetaminophen 650 milligrams PO Q6 hours
b. Digoxin 250 PO daily
c. levothyroxine 75mcg PO daily at 0600
d. ceftriaxone 1 gram IV Q 24 hours
b. Digoxin 250 PO daily
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse indicate in the plan of care?
a. Speak in a neutral tone when addressing the client
b. limit the clients opportunities to socialize with others
c. rotate staff members caring for the client
d. mix the medication with the clients food item
d. administer flumazenil to the client
a. Speak in a neutral tone when addressing the client
A nurse in an outpatient mental health clinic is as- sessing an adolescent client. The nurse should expect the adolescent to be in which of the following of erikson’s stages of psychosocial development?
a. Trust versus mistrust
b. intimacy versus isolation
c. identity versus role confusion
d. generativity versus self absorption
c. identity versus role confusion
A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?
a. Tighten your muscles before relaxing them when using muscle relaxation techniques
b. imagine a situation that has been stimulating for you when practicing guided imagery
c. talk to someone who you admire as the first step in using mindfulness techniques to relax
d. breathe in through your mouth and out through your nose when using deep
breathing exercises
a. Tighten your muscles before relaxing them when using muscle relaxation techniques
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take?
a. Express drainage from the IV site and send it to be cultured
b. apply a pressure dressing at the IV site
c. place a warm moist compress on the site
d. insert a new IV catheter distal to the discontinued IV site
c. place a warm moist compress on the site
A nurse is planning to delegate the fasting blood glu- cose testing for a client who has diabetes mellitus to an assistive personnel.Which of the following actions should the nurse take?
a. Determine if the AP has the skills to perform the test
b. have the AP check the medical record for prior blood glucose test results
c. assign the AP to ask the client if she has taken her antidiabetic medication today
d. help the AP perform the blood glucose test
a. Determine if the AP has the skills to perform the test
A nurse is assessing a child who has bacterial pneu- monia. Which of the following manifestations should the nurse expect?
a. Fever
b. Steatorrhea
c. tinnitus
d. Dysphagia
a. Fever
A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?
a. Speak in a normal voice at a natural pace
b. use gestures when speaking with the client
c. pause in the middle of sentences
d. direct statements to the interpreter
a. Speak in a normal voice at a natural pace
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?
a. Keep your feet together to provide a tight base of support
b. keep objects away from your center of gravity while lifting
c. tighten abdominal muscles to improve balance
d. Bend at the waist when lifting objects from the floor
c. tighten abdominal muscles to improve balance
A nurse is caring for a client who has diabetes mellitus and is receiving a long acting daily insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?
a. NPH insulin
b. insulin aspart
c. glargine insulin
d. regular insulin
c. glargine insulin
A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh. Which of the following actions should the nurse take?
a. Irrigate the wound with sterile water
b. apply a transparent dressing to the wound
c. apply direct pressure to the wound with thick dressing material
d. tie a tourniquet around the leg distilled to the wound
c. apply direct pressure to the wound with thick dressing material
A nurse is caring for a client who experienced a trau- matic brain injury 72 hours ago. Which of the follow- ing findings should the nurse identify as a potential indication of increased intracranial pressure?
a. Hypotension
b. tachycardia
c. increasingly severe headache
d. narrowed pulse pressure
c. increasingly severe headache
A nurse is assessing a 5 year old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
a. Heart rate 140/min
b. capillary refill 3 seconds
c. absence of hypoglycemic episodes
d. cessation of nocturnal enuresis
d. cessation of nocturnal enuresis
A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
a. Keeping a promise to visit with a client who is house bound after the delivery of care
b. ensuring that a client who is homeless receives preventative medical care
c. being honest with the parents of a child about their need to report suspected abuse
d. accepting the decision of an older adult client to live alone in her home
b. ensuring that a client who is homeless receives preventative medical care
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?
a. Place enough formula in the container to last 18 hours
b. check for gastric residual every 12 hours
c. flush the tubing with 30ML of water every four hours
d. maintain bed elevation at 20 degrees
c. flush the tubing with 30ML of water every four hours
A nurse is assessing the grief response of a client whose child died six months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?
a. I know that I will be reunited with my child someday
b. I feel guilty because my child died
c. I am angry that my child died
d. I am unable to feel any joy since my child died
d. I am unable to feel any joy since my child died
A nurse is caring for a client who has respiratory depression from an opioid administration. After administering an naloxone to the client, which of the following findings should the nurse expect?
a. Hypoventilation
b. Hyperglycemia
c. increased pain
d. somnolence
c. increased pain
Which of the following statements should the nurse include in the client’s teaching? Select all that apply
a. Take hot showers to help relieve itching
b. Wear flat or low heeled shoes
c. you can douche twice weekly
d. wear loose fitting clothing
e. try using an abdominal support belt
f. you should avoid fried foods
g. eat two large meals a day
b. Wear flat or low heeled shoes
d. wear loose fitting clothing
f. you should avoid fried foods
A nurse in a prenatal clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indi- cates an understanding of the teaching?
a. My nurse can teach me biofeedback at the beginning of Labor
b. a transcutaneous electrical nerve stimulator will help with pelvic pressure
c. I can use my ultrasound picture as a focal point during contractions
d. the nurse will initiate acupuncture when I arrive at the unit
c. I can use my ultrasound picture as a focal point during contractions
A home care nurse is caring for a client who has advancing multiple sclerosis.
a. Hypertension
b. hypocalcemia
c. calcium reabsorption
d. urinary stasis
e. diarrhea
f. contractures
g. atelectasis
h. pressure injury
b. hypocalcemia
c. calcium reabsorption
f. contractures
g. atelectasis
h. pressure injury
A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?
a. Offer the client three large meals each day
b. ambulate the client before each meal
c. limit fluid intake with meal
d. administer A bronchodilator after meals
c. limit fluid intake with meal
A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest?
a. inform the client that using pharmacological pain management will not impact the delivery
b. provide information about the use of hydrotherapy during labor
c. have the client exhale deeper than she inhales to promote adequate ventilation
d. encourage the client to have the family exit the room when the pain is unbearable
b. provide information about the use of hydrotherapy during labor
A nurse is caring for a client in an outpatient clinic.
Complete the following sentence by using the list of options.
Joints
The client is at risk for developing _______ as evidenced by the client’s _________.
Rheumatoid arthritis ; ESR level
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
a. Inability to carry out a simple task
b. client reports auditory hallucinations
c. moves quickly from one idea to the next
d. client expresses illusions of grandeur
a. Inability to carry out a simple task
A nurse is preparing a client to transfer to a long term rehabilitation facility following a below the knee amputation of the right leg. Which of the following actions should the nurse take to protect the client’s confidentiality?
A. provide a verbal report of the client’s condition to the paramedic performing the transfer
b. Fax the client’s name and identifiable information to the rehabilitation facility
c. e-mail the client’s health information to the facility and an unencrypted file
d. discussed the client’s response to the transfer with another staff nurse
A. provide a verbal report of the client’s condition to the paramedic performing the transfer
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 suspicion of elder abuse?
a. Notify risk management
b. inform the transferring agency of the client’s condition
c. contact the family regarding the client’s condition
d. privately interview the client about the injuries
d. privately interview the client about the injuries
A nurse is caring for a client in active labor.
The nurse is assuming care for the client at 0305.
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
assist client with ambulation
inform client to expect drowsiness
monitor for elevated temp
assess for urinary retention
encourage client to turn from side to side
Essential:
monitor for elevated temp
assess for urinary retention
encourage client to turn from side to side
Contraindicated:
assist client with ambulation
inform client to expect drowsiness
Nurses’ Notes
0800:
A client who has bipolar disorder is admitted to the inpatient psychiatric unit. During the morning assessment, the client reports blurred vision and an increase in urine output. It is noted that the client is having clonic jerking of upper extremities. Provider notified and laboratory tests ordered. Skin is warm and dry without rash.
A nurse is caring for a client.
Exhibits
Complete the following sentence by using the lists of options.
The nurse understands that the patient has likely developed ________ and will need to be monitored for _____.
lithium toxicity
seizure activity
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client’s current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?
A. Complete an incident report and place it in the client’s medical record.
B. Compare the current infusion with the prescription in the client’s medication record.
C. Contact the charge nurse to see if the prescription was changed.
D. Submit a written warning for the nurse involved in the incident.
B. Compare the current infusion with the prescription in the client’s medication record.
Client is admitted to the unit.
They deny suicidal ideations at this time.
Client states, “l am an assistant to a powerful spirit.” Client is poorly groomed and has body odor.
Indicated vs contraindicated
A . Ask the client about the content of their hallucinations.
B . Instruct the client on expected hygiene practices.
C . Assess the client for suicidal ideation.
D . Allow the client to watch TV at a high volume.
E . Place the client in a room near the activity room.
Indicated:
A . Ask the client about the content of their hallucinations.
B . Instruct the client on expected hygiene practices.
C . Assess the client for suicidal ideation.
Contraindicated:
D . Allow the client to watch TV at a high volume.
E . Place the client in a room near the activity room.
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a G3 P2 with one preterm birth.
Day : 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min with occasional accelerations and moderate variability. No uterine contractions noted.
The nurse is continuing to care for the client.
The nurse is reviewing the assessment findings.
For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
A . Blood pressure
B . Elevated alanine aminotransferase (ALT)
C . Platelet count
D . Hemoglobin
Preeclampsia
A . Blood pressure
B . Elevated alanine aminotransferase (ALT)
C . Platelet count
D . Hemoglobin
HELLP
A . Blood pressure
B . Elevated alanine aminotransferase (ALT)
C . Platelet count
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a G3 P2 with one preterm birth.
Select words from the choices below to fill in each blank in the following sentence.
The client is at greatest risk for developing _____ and _____.
seizures
placental abruption
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a G3 P2 with one preterm birth.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client’s condition.
The action the nurse should take first is _____ and then ______
evaluating the fetal heart rate tracing
administering magnesium sulfate IV
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
A. Read medication labels at least two times prior to administration.
B. Avoid preparing medications for more than two clients at one time.
C. Inform clients about the action of each medication prior to administration.
D. Complete an incident report if a client vomits after taking a medication.
B. Avoid preparing medications for more than two clients at one time.
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client’s nutritional requirements?
A. Schedule meals at 6-hr intervals.
B. Maintain calorie intake at 1,500 per day.
C. Keep a calorie count for foods and beverages.
D. Provide a low-protein, high-carbohydrate diet.
C. Keep a calorie count for foods and beverages.
A home health nurse is planning care for a client who has Alzheimer’s disease. Which of the following actions should the nurse include in the plan of care?
A. Encourage physical activity prior to bedtime.
B. Replace the carpet with hardwood floors.
C. Wear clothing with zippers instead of buttons.
D. Place locks at the tops of exterior doors.
D. Place locks at the tops of exterior doors.
6-year-old child.
Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.
Brudzinski’s and Kernig’s signs are positive.
Vital Signs.
Respiratory rate 28/min.
Pulse rate 120/min.
BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.
Vancomycin 300 mg IV q 6 hr following blood cultures.
Acetaminophen 240 mg PO q 6 hr PRN fever.
A nurse is planning care for a child during admission to the facility.
Which of the following actions should the nurse take first?
A. Obtain a prescription for pain medication.
B. Initiate seizure precautions.
C. Collect blood cultures.
D. Transport the child to obtain a CT scan.
B. Initiate seizure precautions.
Child has been brought to the clinic by their parent due to a report of right arm pain. The parent states that several hours ago the child tripped and fell onto the sidewalk while playing outside. The child states, “I was running when we were playing, and I tripped over a curb.” Child is supporting their arm across their body.
Drag words from the choices below to fill in each blank in the following sentence.
The nurse should anticipate a prescription for: _____ and _____.
pain medication
limb immobilization
A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?
A. Place the client’s hands in warm water.
B. Administer a benzodiazepine.
C. Place an ice pack on the client’s perineum.
D. Perform a fundal massage.
A. Place the client’s hands in warm water.
A nurse is educating a client about the prescription for metformin. Which of
the following information should the nurse include?
A. Avoid consuming grapefruit juice with this medication
B. This medication can cause low blood sugar
C. Avoid taking this medication at mealtime
D. The medication can cause dry skin and itchiness
B. This medication can cause low blood sugar
A public health nurse is providing education to a group of caregivers of
children in a community where all the homes are older. Which of the following
screening tests should the nurse recommend for toddlers who are between 1 and 2
years of age?
A. Sickle cell anemia
B. Blood lead level
C. Cystic fibrosis
D. Hereditary hearing loss
B. Blood lead level
A public health nurse is preparing for a mass casualty incident. Which of the
following tasks should the nurse complete during the planning phase of disaster
management?
A. Coordinate care in shelters
B. Participate in practice drills
C. Triage injured individuals
D. Make referrals to support services
B. Participate in practice drills
A charge nurse is inspecting electrical equipment in a client’s room. Which
of the following findings should the nurse identify as a safety hazard?
A. A frayed cord is wrapped with electrical tape
B. The IV pump is placed in an electrically grounded outlet
C. Al electrical cord is taped to the floor near the baseboard
D. The blood pressure machine has a three-prong plug
A. A frayed cord is wrapped with electrical tape
99.A charge nurse is mentoring a newly licensed nurse. Which of the following should
the charge nurse include when teaching about ergonomic principles?
Note: Ergonomics is the study of optimal positioning and comfort to create healthy
and productive work environments.
A. Transfer on the client’s weaker side when moving a client from a bed to a chair
B. Use a lateral transfer device when moving a client from the bed to a stretcher
C. Raise the head of the bed when transferring a client from the bed to a stretcher
D. Use a pillow underneath the client’s head when positioning the client
B. Use a lateral transfer device when moving a client from the bed to a stretcher
A nurse is caring for a client who is speaking incoherently and attempting to remove
their gastrostomy tube. The nurse should anticipate a prescription for which of the
following types of restraint?
A. Chemical
B. Bilateral limb
C. Soft mitts
D. Seclusion
C. Soft mitts
A newly licensed nurse is caring for a client who requires tracheal suctioning, which
is a procedure the nurse has not performed in practice. Which of the following
actions should the nurse take?
A. Identify that the task is in the scope of RN practice and perform the suctioning
B. Delegate the task to an assistive personnel
C. Ask an experienced nurse to assist with the procedure
D. Refuse to take the assignment
C. Ask an experienced nurse to assist with the procedure
A nurse is planning care for a client who has obsessive-compulsive disorder. Which
of the following statements should the nurse plan to include in the teaching about
cognitive reframing?
A. You can decrease anxious thoughts by tensing and releasing your muscles in a systemic way
B. You can have better control over your thoughts by having information about how
your body functions
C. You can decrease irrational thoughts by replacing them with positive ideas
D. You can interrupt your train of thought by focusing on taking slow, deep breaths
A. You can decrease anxious thoughts by tensing and releasing your muscles in a
systemic way
nurse is caring for a school-age child who is deaf. Another nurse on the unit is
certified in American Sign Language (ASL). Which of the following actions should the
second nurse take prior to agreeing to interpret for the client?
A. Ask the guardian if they prefer to interpret for their client
B. Contact the provider for their approval
C. Have an attorney draft a contract for the guardian to sign
D. Review the facility policy for potential legal implications
D. Review the facility policy for potential legal implications
A nurse manager is planning to assist with resolving conflict within a group of
nurses. Which of the following actions should the nurse manager take?
A. Ensure each individual can respond defensively about the conflict
B. Use passive listening techniques during conflict resolution
C. Ask closed-ended questions about the conflict
D. Gather individual information regarding the conflict
D. Gather individual information regarding the conflict
nurse manager is planning a staff education program to discuss ways to improve
cost-effectiveness of care within the facility. Which of the following information
should the nurse manager plan to include during the program?
A. Advocate for increased length of stay to improve client outcomes
B. Choose inexpensive supplies in client care
C. Collaborate with the provider to review necessity of repeat lab tests
D. Keep extra supplies in each client’s room
C. Collaborate with the provider to review necessity of repeat lab tests
nurse manager is facilitating a seminar for newly licensed registered nurses. The
focus of the seminar is to assist the nurse in understanding their scope of practice.
Which of the following information should the nurse manager include in the
seminar?
A. A licensed practical nurse can provide initial discharge instructions
B. An RN can delegate blood administration to a licensed practical nurse
C. An RN can initiate the plan of care for a client on admission
D. An assistive personnel can evaluate a client’s response to medication
C. An RN can initiate the plan of care for a client on admission
nurse is caring for a client who was admitted for delirium treatment 6 hr ago. The
client asked to be discharged immediately. Which of the following responses
should the nurse make?
A. You have to sign a against medical advice form before leaving
B. I am going to call security, you cannot leave the hospital
C. You’ll be given an injection to calm you down
D. I have to place you in restraints for your own safety
A. You have to sign a against medical advice form before leaving
A nurse is caring for an older adult client. Which of the following changes should the
nurse expect for a client who is older than 65 years of age?
A. Increased skin elasticity
B. Increased body water
C. Decreased skeletal muscle mass
D. Decreased sensitivity to pain
C. Decreased skeletal muscle mass
A nurse is teaching the parent of a 3-year-old client about child development.
Which of the following developmental tasks should the nurse include as the child’s
expected cognitive developmental stage?
A. Concrete operational
B. Formal operational
C. Preoperational
D. Sensorimotor
C. Preoperational
A nurse in a community clinic is reviewing the laboratory results for a group of
clients. Which of the following laboratory results should the nurse report to the
local health department?
A. Rotavirus
B. Pertussis
C. Herpes Simplex Virus
D. Group A beta-hemolytic streptococcus
B. Pertussis
A nurse is participating in a disaster planning committee at a large hospital. Which
of the following should be included in the plan?
A. Establishing a protocol to send home ancillary staff during a natural disaster
B. Identifying one outside meeting place to report in the event of an evacuation
C. Develop a plan to evacuate the most critical clients first
D. Making written plans accessible on all the units in the back of a loss of power
C. Develop a plan to evacuate the most critical clients first
A nurse is performing an environmental assessment of a client’s home. Which of
the following findings should the nurse identify as a fire hazard?
A. Seasoned firewood stored in the yard
B. Covers placed on unused electrical outlets
C. A space heater plugged directly into a wall outlet
D. Extension cords placed under area rug
C. A space heater plugged directly into a wall outlet
A nurse is caring for a client who has swelling of the lower extremities. Which of the
following actions should the nurse take when assessing for pitting edema?
A. Determine the edema using a scale of 1 to 5
B. Feel for edema for 1 min
C. Measure the edema in millimeters
D. Measure the circumference of the leg
D. Measure the circumference of the leg
A nurse is caring for the parent of a child who has died from sudden unexpected
infant death. Which of the following statements should the nurse include in the plan
of care?
A. I’d like to provide some information about a support group
B. You must have faith that your child is at peace
C. You should not grieve in front of other people
D. Don’t blame yourself
A. I’d like to provide some information about a support group
A nurse is teaching the parents of a child who has a new onset of seizures and is to
undergo an electroencephalogram (EEG) about the procedure. Which of the following instructions should the nurse include in the teaching?
A. Give the child acetaminophen for pain following the procedure
B. Make the child NPO before the procedure
C. Keep the child out of the sun for 4 hr following the procedure
D. Ensure the child’s hair is clean and without conditioner before the procedure
D. Ensure the child’s hair is clean and without conditioner before the procedure
A nurse is providing teaching to a client about three-point gates using crutches.
Which of the following statements by the client indicates an understanding of the teaching?
A. I could lean on my crutches for support when walking
B. I should keep my elbows straight when walking
C. I should move my affected leg with the crutches when initially walking
D. I should place all my weight on my effective leg when walking
C. I should move my affected leg with the crutches when initially walking
A nurse is caring for a client who is at the end-of-life. Which of the following
common manifestations should the nurse expect to cause the client the most
anticipatory distress?
A. Fatigue
B. Dysphagia
C. Mottling
D. Pain
D. Pain
A nurse is preparing to catheterize a toddler for a urine culture. Which of the
following is an appropriate action for the nurse to take?
A. Don sterile gloves prior to the procedure
B. Discard the first 10 mL of urine
C. Obtain 12-french catheter
D. Apply EMLA cream prior to the procedure
A. Don sterile gloves prior to the procedure
A nurse is providing information for a client who has a new prescription for
simvastatin. For which of the following should the nurse instruct the client to
monitor and report to the provider?
A. Fever
B. Edema
C. Muscle weakness
D. Weight loss
C. Muscle weakness
A nurse is planning care for a client who is dying. Which of the following interventions should the nurse plan to take?
A. Change the client’s position every 4 hrs
B. Institute nonpharmacological comfort measures for the client
C. Maintain a three-meal-per-day schedule for the client
D. Administer IV hydration for the client
B. Institute nonpharmacological comfort measures for the client
A nurse is leading a grief support group. Which of the following statements by a
participant should the nurse identify as an indication of an appropriate grief response?
A. I feel emotionally numb and no longer leave the house
B. I lost trust in healthcare professionals since they died
C. I am sad but recognize that this was a blessing for them
D. I think a part of me died with them. I feel empty inside
C. I am sad but recognize that this was a blessing for them
A nurse is assessing an older adult client. Which of the following statements by the
client indicates a need for teaching about sexual health?
A. I still have risks for sexually transmitted infections with new partners
B. Painful intercourse means I should not have sexual intercourse
C. Some of my medicines may affect my sexual functioning
D. Staying sexually active is beneficial for my health
B. Painful intercourse means I should not have sexual intercourse
A nurse is reviewing the medical record of a client who had abdominal surgery 2
days ago. The nurse should identify that which of the following findings indicate the
client is at risk for delayed wound healing?
A. Oxygen saturation 97% on room air
B. Capillary refill time 1 second
C. Pain level of 1 on a scale of 1 to 10
D. BMI 35
D. BMI 35
A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The
nurse should identify which of the following findings indicates altered tissue perfusion on the affected extremity?
A. Pain with movement on the right left great toe
B. Purulent drainage at the pin site
C. Faint pedal pulses of the left leg
D. Warm skin temperature distal tip in sight
C. Faint pedal pulses of the left leg
72.A nurse is caring for an adult client who has chronic anemia and is scheduled to
receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
A. Administer the blood via a 21-gauge IV needle
B. Check the client’s vital signs from the previous shift prior to the initiation of the
transfusion
C. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
D. Set the IV infusion pump to administer the blood over 6 hrv
C. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?
A. Weight gain
B. Thready pulse
C. Tachycardia
D. Decreased thirst
A. Weight gain
A nurse is providing teaching to a client who has a new diagnosis of multiple
sclerosis. Which of the following statements should the nurse make?
A. Use a cane when walking to maintain your balance
B. Place a scatter rug in your bathroom to prevent falling
C. Engage in rigorous exercise programs to maintain muscle tone
D. Plan to take a hot bath once a week to reduce stress
A. Use a cane when walking to maintain your balance
A nurse is verifying a record of informed consent for a client who is scheduled for
surgery. Which of the following actions should the nurse take?
A. Confirm the client’s signature is authentic
B. Provide information on the informed consent about the benefits of surgery
C. Inform the client about the condition that requires treatment
D. Explain the procedure to the client before verifying informed consent
A. Confirm the client’s signature is authentic
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?
A. Deliver breaths manually with a resuscitation bag
B. Decrease the ventilator flow rate
C. Assess for disconnected tubing
D. Reevaluate the client for an ET cuff leak
A. Deliver breaths manually with a resuscitation bag
A nurse is preparing to administer PRN pain medication to a client who has
cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer?
Note: Cholelithiasis is the presence of gallbladder stones in the gallbladder
A. Omeprazole
B. Acetaminophen
C. Metoclopramide
D. Ketorolac
D. Ketorolac
A nurse is caring for a client who has diarrhea and is receiving intermittent enteral
feedings. Which of the following actions should the nurse take?
A. Administer feedings at a slower rate
B. Provide chilled formula
C. Discard the open can of formula after 36 hr
D. Flush the tube with 10 mL of water after feedings
A. Administer feedings at a slower rate
A nurse is planning a community health program about Parkinson’s disease. Which of the following interventions should the nurse include as a tertiary prevention
strategy?
A. Provide daily exercise classes to improve ambulation for clients who have Parkinson’s disease
B. Educate clients about common techniques used to diagnose Parkinson’s
disease
C. Educate clients who are at risk for Parkinson’s disease about maintaining a low-
cholesterol diet
D. Provide screenings for community health members to identify early
manifestations of Parkinson’s disease
A. Provide daily exercise classes to improve ambulation for clients who have Parkinson’s disease
A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?
A. Drink at least 3 L of fluid daily
B. Take magnesium hydroxide for indigestion
C. Consume foods high in potassium
D. Eat 1g/Kg of protein per day
D. Eat 1g/Kg of protein per day
A nurse observed a client on a psychiatric unit muttering and standing near a window. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse?
A. Do you recognize the voices as belonging to anyone you know?
B. You shouldn’t be afraid when you think the voices are telling you to hurt yourself.
C. I understand the voices are frightening you, but I do not hear any voices
D. That can’t be true. The only voices in this room are yours and mine.
C. I understand the voices are frightening you, but I do not hear any voices
A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?
A. Place a large pillow under the knees when sleeping
B. Take a hot shower every day
C. Limit dietary intake of phosphorus
D. Place an ice pack directly on the skin of the affected joints
B. Take a hot shower every day
A nurse is teaching a client about condom use. Which of the following client
statements should the nurse identify as an understanding of the teaching?
A. I can re-use the condom one time after initial use
B. I can store the condoms in the drawer of my nightstand
C. I can use petroleum jelly as a lubricant with the condom
D. I can use natural-skin condoms to prevent sexually transmitted infections
B. I can store the condoms in the drawer of my nightstand
A nurse is teaching a client who has a new prescription for an MAOI. Which of the
following foods is contraindicated with this medication?
A. Grapefruit
B. Cheese
C. Eggs
D. Potatoes
B. Cheese
A nurse is providing discharge teaching for a client who has a new implantable
cardioverter (ICD). Which of the following client statements demonstrates understanding of the teaching?
A. I can hold my cell phone on the same side of my body as the ICD
B. I will wear loose clothing over my ICD
C. I will avoid using my microwave oven at home because of the ICD
D. I will soak in the tub rather than showering
B. I will wear loose clothing over my ICD
A nurse is caring for a 1-day old newborn who has jaundice and is receiving
phototherapy. Which of the following actions should they take?
A. Apply lotion to the newborn every 4 hr
B. Keep the infants head covered with a cap
C. Give the infant 30 mL (1oz) of glucose water every 2 hr
D. Ensure that the newborn wears a diaper
D. Ensure that the newborn wears a diaper
A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which of the following findings should the nurse expect?
A. Increased bicarbonate
B. Increased calcium
C. Increased creatinine
D. Increased hemoglobin
C. Increased creatinine
A nurse in the emergency department is assessing a newly admitted client who is
experiencing drooling and hoarseness following a burn injury. Which of the following
actions should the nurse take first?
A. Apply 100% humidified oxygen
B. Obtain a blood specimen for ABG analysis
C. Insert an 18-gauge IV catheter
D. Obtain a baseline ECG
A. Apply 100% humidified oxygen
A nurse is caring for a client who is experiencing increased intracranial pressure
following a head injury. In which of the following positions should the nurse place the client?
A. Left lateral
B. Sim’s
C. Low-Fowler’s
D. Supine
C. Low-Fowler’s
A nurse is assessing a client who has Obsessive-compulsive personality disorder. Which of the following findings should the nurse expect?
A. Lack of empathy
B. Goal-oriented
C. Provocative behavior
D. Lability
B. Goal-oriented
A nurse is caring for a client who is experiencing status epileptics. Which of the
following medications should the nurse expect to administer?
A. Lamotrigine
B. Carbamazepine
C. Lorazepam
D. Clonazepam
C. Lorazepam
A home health nurse is assessing a client who has amyotrophic lateral sclerosis
(ALS) and has had recent weight loss. Which of the following is the priority
admission data for the nurse to obtain?
A. Swallowing ability
B. Prescribed medications
C. Changes in appetite
D. Daily fluid intake
A. Swallowing ability
A nurse is caring for a client who has a new diagnosis of schizophrenia and a
prescription for an antipsychotic medication. The nurse should recognize that
which of the following indicates an adverse effect that must be reported to the
provider?
A. The client is observed mumbling quietly while alone in the day room
B. The client is observed displaying a shuffling gait while walking in the hall
C. The client states, “I feel light-headed when I stand up quickly
D. The client states, “being in the sun seems to really hurt my eyes.”
B. The client is observed displaying a shuffling gait while walking in the hall
A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?
A. Request a change in medication from the provider
B. Review the client’s electronic pain diary
C. Set up an appointment with the school nurse
D. Refer the family to a chronic pain support group
B. Review the client’s electronic pain diary
A nurse is teaching a client about bladder retraining for incontinence. Which of the
following instructions should the nurse include in the teaching?
A. Limit oral fluid intake to 1,000 milliliters per day
B. Wear a pair of disposable briefs at bedtime
C. Drink 8 ounces of citrus juice per day
D. Practice pelvic floor exercises regularly
D. Practice pelvic floor exercises regularly
A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? SATA
A. Allow extra time for the client to perform tasks
B. Approach the client from the side
C. Ensure there is high-wattage lighting in the client’s room
D. Touch the client gently to announce presence
E. Keep objects in the client’s room in the same place
A. Allow extra time for the client to perform tasks
C. Ensure there is high-wattage lighting in the client’s room
E. Keep objects in the client’s room in the same place
A nurse is providing discharge teaching to a new parent about breastfeeding her
infant. Which of the following statements should the nurse take?
A. Limit the time your infant feeds to 10 minutes on each breast
B. Offer your infant the breast when he shows signs of hunger
C. Begin each feeding using the same breast
D. Supplement breastfeeding with water every 12 hours
B. Offer your infant the breast when he shows signs of hunger
A nurse is caring for a client who has experienced stillbirth. Which of the following
actions should the nurse take during the initial grieving process?
A. Offer to take pictures of the newborn for the client
B. Discourage the client from allowing friends to see the newborn
C. Assure the client that she can have additional children
D. Avoid talking to the client about the newborn
A. Offer to take pictures of the newborn for the client
41.A nurse is providing teaching to an older adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions should the
nurse include?
A. Limit foods that contain vitamin D while taking this medication
B. Limit foods that contain folic acid while taking this medication
C. Plan to take this medication with food
D. Plan to take this medication with antacids
C. Plan to take this medication with food
A nurse is updating the plan of care for a client who has amyotrophic lateral
sclerosis with dysphagia. Which of the following instructions should the nurse
include in the teaching?
A. Avoid high-fiber foods while taking this medication
B. Avoid hot tubs while wearing the patch
C. Apply the patch to your forearm
D. Remove the patch for 8 hours every day to reduce the risk of tolerance
B. Avoid hot tubs while wearing the patch
A nurse is teaching a client who plans to begin following vegan dietary guidelines.
Which of the following information should the nurse include?
A. Limit intake of foods high in vitamin C
B. Choose foods high in Vitamin B12
C. Limit intake of nuts and legumes
D. Choose high-fat cheese as a meat substitute
B. Choose foods high in Vitamin B12
A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following intervention should the nurse include in the plan of care?
A. Administer antibiotics intermittent IV bolus for 24-hour period
B. Monitor the child’s cardiac status
C. Give scheduled doses of acetaminophen every 6 hours
D. Provide stimulation when with children of the same age in the playroom
B. Monitor the child’s cardiac status
A nurse is admitting a client who has acute heart failure. Which of the following
prescriptions from the provider should the nurse anticipate?
A. Administer enalapril 2.5 mg PO twice daily
B. Ambulate the client every 4 hr while awake
C. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr
D. Provide the client with a 4 g sodium diet
A. Administer enalapril 2.5 mg PO twice daily
A nurse is contributing to the plan of care for a client who has multiple sclerosis.
The nurse should recommend including which of the following interventions in the
plan of care to assist the client in overcoming barriers related to this condition?
A. Provide the client with large handled eating utensils
B. Establish alternatives to verbal communication
C. Touch the client’s arm before beginning to speak
D. Use the numbers on a clock to describe the position of food on the client’s plate
A. Provide the client with large handled eating utensils
A nurse is providing teaching to a client who is undergoing radiation therapy and has
stomatitis. Which of the following responses by the client indicates an understanding of the teaching?
A. I should use a soft-bristle toothbrush to clean my teeth after meals
B. I should limit my intake of dairy products to prevent nausea
C. I should gargle with an alcohol-based mouthwash to kill germs
D. I should moisten my lips with lemon-glycerin swabs
A. I should use a soft-bristle toothbrush to clean my teeth after meals
A nurse is caring for a client who is recovering from a cerebrovascular accident in a
rehabilitation facility. The client tells the nurse, “I am sick of being in here, and I want to go home.” Which of the following responses should the nurse make?
A. It must be very frustrating for you to be here
B. You should call your partner to discuss this
C. You are making progress in your treatment plan
D. It would be best to discuss your feelings with your provider
A. It must be very frustrating for you to be here
A nurse is caring for a client who has systemic lupus erythematosus. Which of the
following client findings should the nurse expect?
A. Kaposi’s sarcoma lesions
B. Hemangiomas
C. Raised facial rash
D. Psoriasis
C. Raised facial rash
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects
should monitor the client?
A. Flushed face
B. Negative clonus
C. Pulse rate 100/min
D. BP 150/92 mm Hg
B. Negative clonus
A nurse is making an initial postpartum home visit. Which of following client
statements should the nurse identify as a manifestation of increased risk of child
abuse?
A. I want to meet other parents to see if they are going through the same thing
B. I try to respond to the baby quickly so she doesn’t cry very long
C. I think the baby should be sleeping through the night by now
D. I have several friends who come by to help out with the baby
C. I think the baby should be sleeping through the night by now
A nurse providing discharge teaching about car seat safety to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
A. I will place my baby in a forward-facing car seat in my back seat
B. I can place my baby in the front seat with the airbag turned oX
C. I can turn my baby’s car seat around when she weighs 15 pounds
D. I will position my baby at a 45-degree angle in the car seat
D. I will position my baby at a 45-degree angle in the car seat
A nurse is providing teaching to a client who has thrombocytopenia following
chemotherapy. Which of the following statement indicates an understanding of the
teaching?
A. I will remove my shoes when inside the house
B. I will use an enema to manage my constipation
C. I will wipe my nose instead of blowing
D. I will floss between my teeth every time I brush
C. I will wipe my nose instead of blowing
A nurse is caring for a client who received 50,000 units of IV heparin rather than the
prescribed 5,000 units. Which of the following actions should the nurse take first?
A. Complete an incident report
B. Notify the risk manager
C. Check the client for indications of bleeding
D. Monitor the client aPTT levels
C. Check the client for indications of bleeding
A nurse is teaching the parents of a school-age child who is newly diagnosed with
juvenile idiopathic arthritis. Which of the following should the nurse include in the
teaching?
A. Have the child take a tub bath each morning.
B. Apply splints to the child’s extremities during the day
C. Encourage the child to take naps during the day
D. Keep the child on bed rest as long as pain persists
A. Have the child take a tub bath each morning.
A nurse is observing a newly licensed nurse who is administering total parenteral
nutrition (TPN) to a client. Which of the following actions by the newly licensed
nurse indicates a need for the nurse to intervene?
A. Plans for a check of the client’s fingerstick glucose level every 6 hr
B. Gradually increase the TPN infusion rate each hour until the prescribed rate is
achieved
C. Schedules a bag and tubing change for 24 hr after the start of the infusion
D. Uses the TPN IV tubing to administer the client’s next dose of antibiotics
D. Uses the TPN IV tubing to administer the client’s next dose of antibiotics
A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer. Which of the following information should the nurse include?
A. Wash your skin thoroughly with a washcloth after each treatment
B. Wear a binder over the radiation site
C. Use rubbing alcohol to remove the ink markings
D. You might experience altered taste sensations
D. You might experience altered taste sensations
A nurse is providing teaching to a client who has diabetes mellitus about the
glycosylated hemoglobin blood test. Which of the following statements by the client
indicates an understanding of this test?
A. I will need to drink a glucose solution to get an accurate result
B. I will use this test to monitor how well I control my blood glucose levels
C. I will need to fast prior to taking this test
D. I will use the result of this test daily to modify my insulin dosage
B. I will use this test to monitor how well I control my blood glucose levels
A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg
(15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?
A. 13.3%
B. 15%
C. 8.1%
D. 7.5%
D. 7.5%
A nurse is creating a plan of care for a client who has cancer and is experiencing
immunosuppression. Which of the following interventions should the nurse include
in the plan of care?
A. Monitor the client’s vital signs every 12 hr
B. Rotate health care staff caring for the client
C. Inspect the client’s mouth every 8 hr
D. Provide fresh fruit with the client’s meals
C. Inspect the client’s mouth every 8 hr
A nurse is planning care for a client who is returning to the unit following open
gastric bypass surgery. Which of the following interventions should the nurse
include in the client’s plan of care?
A. Measure and compare abdominal girth daily
B. Provide a soft diet on the first operative day
C. Provide a 60 mL of fluid intake every 5 min
D. Ambulate the client 48 hr after the procedure
A. Measure and compare abdominal girth daily
A nurse is providing discharge teaching for the guardian of a school-age child
following a cardiac catheterization. Which of the following instructions should the nurse include in the teaching?
A. Your child should stay out of school for 7 days following the procedure
B. Your child can take a tub bath this evening
C. You should give your child a clear liquid diet for 24 hr
D. You should remove your child’s pressure dressing tomorrow
D. You should remove your child’s pressure dressing tomorrow
A nurse is teaching a parent of a school-age child who is to begin a daily dose of
methylphenidate. Which of the following should the nurse include in the teaching?
A. Your child should avoid excess sodium intake
B. You should administer the medication at bedtime
C. Your child should avoid foods containing tyramine
D. You should administer the medication after breakfast
D. You should administer the medication after breakfast
A nurse is preparing to administer an IV medication to a client and accidentally
punctures the IV bag, causing the medication to leak on the counter. Which of the
following medications requires the nurse to follow facility procedures in the safe
handling of a biohazard material spill?
A. Metronidazole
B. Doxorubicin hydrochloride
C. Ampicillin sodium
D. Phenytoin
B. Doxorubicin hydrochloride
A nurse is discussing treatment options with a client who is experiencing nicotine
withdrawal. Which of the following information should the nurse include in the
teaching?
A. Limit use of nicotine gum to 6 months
B. Substitute tobacco use with an electronic cigarette
C. Use progressively larger nicotine patches
D. Use up to 40 nicotine lozenges per day
A. Limit use of nicotine gum to 6 months
A nurse is assessing the skin turgor of an older adult client. In which of the following
areas should the nurse lift the skin?
A. Neck
B. Abdomen
C. Shoulder
D. Sternum
D. Sternum
A nurse is providing teaching to a parent of a child who has varicella. Which of the
following statements should the nurse include in the teaching?
A. Your child can return to school after a negative titer result
B. Your child can return to school once the fever has subsided
C. Your child can return to school once the lesions have crusted over
D. Your child can return to school 24 hr after beginning antibiotics
C. Your child can return to school once the lesions have crusted over
A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?
A. Flattening of the artificial airway cuff
B. Presence of a productive cough
C. Thinning of mucous secretions
D. Decreased peak inspiratory pressure
D. Decreased peak inspiratory pressure
A nurse in the emergency department is receiving report on a group of clients.
Which of the following clients should the nurse assess first?
A. A client who has orthostatic hypotension and 4+ pitting edema
B. A client who has a complete femur fracture and reports a pain level of 7 on a
scale from 0 to 10.
C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG
D. A client who has a Clostridium diXicile and a temperature of 38.6 C (101.5 F)
C. A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A nurse is evaluating the laboratory values of a client who is receiving Epoetin Alfa.
Which of the following findings indicates a therapeutic response to this medication?
A. Increased platelet count
B. Increased hemoglobin level
C. Increased neutrophil
D. Increased erythrocyte sedimentation rate
B. Increased hemoglobin level
A nurse manager is preparing to meet with a group of staX nurses who are
experiencing conflict. Which of the following mediation strategies should the nurse
manager plan to implement to resolve the conflict?
A. Facilitate discussion until all parties agree
B. Direct anyone who becomes angry to leave the room
C. Establish demands from each party that allow for negotiations
D. Determine who is at fault in the situation
A. Facilitate discussion until all parties agree
A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to
assess the newborn’s pain?
A. Visual analog scale (VAS)
B. FACES pain rating scale
C. Neonatal Infant Pain Scale (NIPS)
D. Premature Infant Pain Profile (PIPP)
C. Neonatal Infant Pain Scale (NIPS)
A nurse is assessing a client who is in active labor. Which of the following findings
should the nurse report to the provider?
A. Contractions lasting 80 seconds
B. Early decelerations in the FHR
C. Temperature 99.3F
D. FHR baseline 170/min
D. FHR baseline 170/min
A nurse is assigning tasks to an assistive personnel. Which of the following tasks should the nurse assign to the AP?
A. Perform postmortem care
B. Suction a new tracheostomy
C. Change a dressing on an implanted central venous access device
D. Remove an NG tube
A. Perform postmortem care
A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five
minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?
A. Infuse 500 mL Lactated Ringer’s IV
B. Administer epinephrine subcutaneously
C. Place the blood bag in a biohazard bag before discarding
D. Document the reaction in the medical record
D. Document the reaction in the medical record
A nurse is planning the administer vancomycin IV to a client. Which of the following
actions should the nurse take to reduce the risk of an adverse reaction to
vancomycin?
A. Give the dose over 60 min
B. Administer the medication undilute
C. Obtain a trough level 30 min after the medication infusion
D. Inject 1% lidocaine prior to each dose
A. Give the dose over 60 min
A nurse is planning care for a client who is scheduled to receive a peripherally
inserted central catheter in the arm. Which of the following interventions is
appropriate for the nurse to include in the plan of care?
A. Administer sedation for the procedure
B. Use gauze to secure an arm board to the involved extremity
C. Schedule an MRI post-procedure to verify the placement
D. Measure the arm circumference above the insertion site daily
D. Measure the arm circumference above the insertion site daily
A nurse on a medical-surgical unit is planning care for assigned clients. Which of the
following actions should the nurse plan to take to demonstrate effective time
management?
A. Delay cleaning personal work area until the end of the shift.
B. Gather supplies for a client’s dressing change after removing the old dressing.
C. Document assessment findings and interventions after providing care for a
group of clients.
D. Complete activities for one client before moving to the next client.
D. Complete activities for one client before moving to the next client.
A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse identify as a manifestation of pulmonary congestion?
A. Frothy, pink sputum
B. Weight gain
C. Bradypnea
D. Jugular vein distention
A. Frothy, pink sputum
A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?
A. Document the client’s refusal in the medical record
B. Notify risk management about the client’s refusal
C. Inform the client that the transfusion is mandatory
D. Suggest that the client explore alternative therapies
A. Document the client’s refusal in the medical record
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 elder abuse?
A. Notify risk management
B. Inform the transferring agency of the client’s condition
C. Contact the family regarding the client’s condition
D. Privately interview the client about the injuries
D. Privately interview the client about the injuries
