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A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel? -----CORRECT ANSWER-----------a. Collecting a stool specimen to test for occult blood. A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report? -----CORRECT ANSWER-------- ---c. A client is found lying on the floor next to a chair. A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan? -----CORRECT ANSWER-----------c. Refer the client to a diabetic support group. A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monitor? ----- CORRECT ANSWER-----------a. Clammy Skin A female client who is an abusive marriage has discusses with the nurse strateg
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A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel? -----CORRECT ANSWER-----------a. Collecting a stool specimen to test for occult blood. A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report? -----CORRECT ANSWER-------- ---c. A client is found lying on the floor next to a chair. A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan? -----CORRECT ANSWER-----------c. Refer the client to a diabetic support group. A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monitor? ----- CORRECT ANSWER-----------a. Clammy Skin A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse. which of the following client statements indicate an understanding of an appropriate strategy? -----CORRECT ANSWER-----------a. "I need to recognize the signs that my husband is becoming abusive." c. "I need to identify what triggers my husband's anger to prevent his abuse." A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP) has no documented the client's blood glucose level. Which of the following actions should the charge nurse take first? -----CORRECT ANSWER-----------d. Determine if the AP has completed the assignment. A client is scheduled for an outpatient colonoscopy. which of the following actions is a nursing responsibility in the informed consent process? -----CORRECT ANSWER--------- --a. Verify that there is a signed and witnesses consent form in the client's chart.
A nurse smells alcohol on the breath of an assistive personnel (AP) during report. Which of the following actions should the nurse take? -----CORRECT ANSWER----------- c. Report the situation to the nurse manager. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? -----CORRECT ANSWER-----------b. A client who had a cesarean delivery 24hr ago. A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cystic fibrosis. Which of the following supports a diagnosis of cystic fibrosis? -----CORRECT ANSWER-----------a. Frothy stools. When caring for an assigned group of clients, the nurse should wear gloves when ----- CORRECT ANSWER-----------a. performing oral hygiene. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take? -----CORRECT ANSWER-----------b. contact security personnel to place the money in the facility safe. A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration? -----CORRECT ANSWER-----------d. Subcutaneously. A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The nurse should instruct the parents to place the car seat in a? -----CORRECT ANSWER--- --------c. Rear-facing position in the back seat. A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations? -----CORRECT ANSWER-----------a. A hospital risk manager includes information from a client's medical record in A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take? -----CORRECT ANSWER----------- c. Notify the charge nurse of the finding.
A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid? -----CORRECT ANSWER-----------a. Ice Cream A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing. Which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases? -----CORRECT ANSWER-----------d. "This will indicate how much acid is building up in my blood." A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following client care situations should the nurse manager intervene? -----CORRECT ANSWER-----------a. A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now producing blood-streaked sputum. For which of the following should the nurse expect the client to have diagnostic testing? -----CORRECT ANSWER----------
A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child? -----CORRECT ANSWER-----------b. "I will encourage my child to wear a bicycle helmet whenever bike riding." A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit? -----CORRECT ANSWER-----------c. Orthostatic hypotension. A nurse is caring for a client who is receiving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------d. Withhold the ordered dose of the medication. A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching? -----CORRECT ANSWER-----------d. The infant is lying in the crib with a stuffed animal. A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B? ----- CORRECT ANSWER-----------a. Performing oral hygiene. A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain? -----CORRECT ANSWER-----------a.? A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following? -----CORRECT ANSWER-----------b. from onset of symptoms until 24hrs of antibiotic therapy. A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the "felt something pop" when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first? -----CORRECT ANSWER-----------c. Cover the wound with sterile saline-soaked gauze.
ANSWER-----------d. A client who has COPD and dementia and was agitated during the night shift. A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use? -----CORRECT ANSWER-----------a. Leave space between the tip of the penis and the end of the condom catheter. A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------b. Ask the client to flex the hips and knees. A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------c. Reinforce safe meal setup techniques. A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states, "I will? -----CORRECT ANSWER-----------a. Install gates at the top and bottom of the stairs." A nurse is preparing a sterile field to perform a dressing change. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------a. Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field. A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states, -----CORRECT ANSWER-----------d. "I guess I have to take some of the blame because of the way my friends and I dress." A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client? -----CORRECT ANSWER-----------d. 4 tablets. A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching? ----- CORRECT ANSWER-----------c. "I will walk barefoot to prevent slipping." d. "I will check my smoke alarms once a month."
A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate? -----CORRECT ANSWER-----------d. "Your windpipe is inflamed and constricted." A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client? ----- CORRECT ANSWER-----------b. Irritability. A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparation classes. Which of the following responses by the nurse supports the partner's involvement during labor? -----CORRECT ANSWER-----------b. "Breathing with your partner will help her to relax during contractions." A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first? -----CORRECT ANSWER-------- ---d. Remove the tracheostomy inner cannula. A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching? -----CORRECT ANSWER-----------a. Wash the bed linens in hot water. d. Clean the child's toys with 1:10 bleach solution. A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate? -----CORRECT ANSWER-----------c. Encourage the client to share her feelings. A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation an is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity? -----CORRECT ANSWER-----------d. chromosomal abnormalities. A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching? -----CORRECT ANSWER-----------d. Nicotinic Acid (niacin)
A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using? -----CORRECT ANSWER-----------d. Rationalization. A nurse is reinforcing teaching with a new mother of a full-term newborn about breastfeeding. The newborn is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching? -----CORRECT ANSWER-----------c. "I should have my baby latch on to my nipple and areola during feeding." A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous sulfate (Feosol) in liquid form. Which of the following statements made by the parent indicates the teaching was effective? -----CORRECT ANSWER-----------a. "I will give the iron through a straw." A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? -----CORRECT ANSWER-----------d. 150 mL/hr A nurse is reinforcing teaching to a group of adolescent males. Which of the following statements made by a student indicates a need for further teaching? -----CORRECT ANSWER-----------d. "I should perform a self-exam of my testes once a year." An infant is admitted to a pediatric unit following a motor-vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure? -----CORRECT ANSWER-----------a. Decreased motor response. A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the following interventions is consistent with the goals of this type of care? ----- CORRECT ANSWER-----------b. Allowing the family overnight visitation. A nurse in an inpatient psychiatric unit is a caring for a client who was raised in an Asian culture. Which of the following communication techniques demonstrates cultural sensitivity? -----CORRECT ANSWER-----------d. Holding eye contact for brief instances. A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------b. Instruct the client to take slow, deep breaths.
A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is the appropriate action for the nurse to take? -----CORRECT ANSWER-----------b. Provide the client with written information about advance directives. A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse should document this as which of the following? -----CORRECT ANSWER----------
Which of the following behaviors is the client likely demonstrating? -----CORRECT ANSWER-----------a. Splitting A nurse is planning a health-promotion program for high school students. Which of the following facts about cigarette smoking is likely to be most effective in changing the adolescents' attitudes towards smoking? -----CORRECT ANSWER-----------c. Smoking causes unattractive stains on the teeth and hands. A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following? -----CORRECT ANSWER-----------d. Vitamin D A nurse is caring for a client who has esophageal cancer. A gastrostomy tube is in place and the client is receiving continuous tube feedings. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------a. Keep the head of the bed elevated at least 30 degrees. A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of car seat. Which of the following statements by a parent indicates an understanding of the teaching? -----CORRECT ANSWER-----------a. "I can place a rolled towel on each side of my newborn's head until he can hold his head up." A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following actions should the nurse take before applying the sensor? -----CORRECT ANSWER----- ------a. Check the client's capillary refill. A nurse is caring for a client who is asking about the technique of eTheurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique? -----CORRECT ANSWER-----------c. "It is a light stroking of the skin during a uterine contraction." A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoperative pain. Which of the following is an adverse effect of this medication? ----- CORRECT ANSWER-----------c. Urinary Retention. A nurse is administering medication. A client states, "I know that the Inderal helps my blood pressure, but I don't like the way it makes me feel. I don't think I'll take it today."
Which of the following actions should the nurse take? -----CORRECT ANSWER----------- c. Ask the client to describe what he is experiencing. A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate? -----CORRECT ANSWER-----------b. "think about a pleasant memory as you visualize your pain floating away." A nurse is caring for an older adult client who is postoperative following a total hip replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the nurse should? -----CORRECT ANSWER-----------d. Apply moisture-absorbing undergarments. A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe? --- --CORRECT ANSWER-----------a. Pseudoephedrine (Sudafed) A nurse is provider's office is reinforcing teaching to the parents of a school-age child who has an ankle sprain. The nurse should include which of the following statements in the teaching? -----CORRECT ANSWER-----------A. "offer aspirin every 4 hours for discomfort." c. "elevate the affected extremity to a level higher than the heart." A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for further data collection? A. Inappropriate words when speaking. -----CORRECT ANSWER-----------D. Sharp sensation when touched with safety pin point. A nurse is reinforcing teaching regarding management of penetrating eye injuries with a parent of a school-age child during a sports physical. Which of the following statements by the child's parent indicates an understanding of the teaching? -----CORRECT ANSWER-----------???? A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching? ----- CORRECT ANSWER-----------b. "the harness promotes hip joint development." A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the
A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylactic reaction? -----CORRECT ANSWER-----------a. Wheezes b. Hypotension A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention? -----CORRECT ANSWER-----------a. Place the client in a room that is ventilated to the outside. A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report? -----CORRECT ANSWER-----------c. A client had a blood glucose of 140mg/dL. A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulate insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first? -----CORRECT ANSWER-----------a. Inject 10 units of air into the NPH insulin vial. A nurse discovers a fire in the trash can of a client's room. Which of the following actions should the nurse take first? -----CORRECT ANSWER-----------a. Escort the client to a secure area. A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action? -----CORRECT ANSWER-----------c. Maintain hyfrophillic material deep into the ulcer. A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching? -----CORRECT ANSWER-----------d. I will call my provider if I experience a yellow tinge to my vision. A nurse receives a verbal order for a client to receive a stat dose of meperidine (demerol) 100 mg PO. she administers the medication, charts the administration, and then realizes she has administered Phentoin (dilantin) 100 mg PO. After obtaining the client's vital signs, which of the following actions should the nurse take? -----CORRECT ANSWER-----------d. Notify the provider.
A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take? -----CORRECT ANSWER-----------a. Verify with another nurse when calculating a new dose of medication. A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. for which of the following should the nurse instruct the client to monitor and report to the provider immediately? -----CORRECT ANSWER-----------d. Sore throat. A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients' statements indicate to the nurse a need for further teaching? -----CORRECT ANSWER-----------d. "I will soak my feet in warm water every night." A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intervene? -----CORRECT ANSWER-----------a. "I have to sleep sitting up." A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching? -----CORRECT ANSWER-----------d. "I will leave the patch on for 12 to 14 hours each day." A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error? -----CORRECT ANSWER-----------a. Incident report A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement? --- --CORRECT ANSWER-----------d. Take the client for a walk to the recreation room. A nurse is reinforcing teaching about levothyroxine (synthroid) to a client has hypothyroidism. Which of the following should the nurse instruct the client to expect? ----
A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring insulin injections. Which of the following statements made by the client indicates understanding of the teaching? -----CORRECT ANSWER-----------b. I should remove bubbles from the syringe before injecting my insulin. A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to take lithium?" Which of the following is an appropriate response by the nurse? ----- CORRECT ANSWER-----------b. "Medication is usually continued for 6 months after symptoms subside. A nurse in the birthing unit is assisting with the care of a client who is at 38 weeks gestation and has bring red vaginal bleeding but denies pain? -----CORRECT ANSWER-----------c. Placenta previa. A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of neural tube defects with a client who is planning to become pregnant. -----CORRECT ANSWER-----------c. Cooked spinach The parent of a 3-year-old child tells the nurse that he is concerned because his daughter has begun playing with an imaginary friend. Which of the following is an appropriate response by the nurse? -----CORRECT ANSWER-----------a. This is a common behavior for children of this age. A nurse is reinforcing teaching regarding home care with a client who is scheduled for discharge following a coronary artery bypass graft. understands teaching? ----- CORRECT ANSWER-----------a. I can begin my cardiac rehabilitation program within the week. A mother of two small children tells the nurse, "I just don't know what to do about my cancer. I've seen three doctors, and each one recommended a different treatment options." appropriate response. -----CORRECT ANSWER-----------c. Arranging a conference with your providers is something I could assist you with. A nurse is reinforcing discharge instructions for an older adult client regarding management of hypertension. Which of the following should the nurse instruct the client to do when evaluating for the presence of orthostatic hypotension? -----CORRECT ANSWER-----------b. Take a blood pressure reading while sitting and another one 2 min later while standing.
A nurse is reinforcing teaching with a client who is scheduled to undergo a fiberoptic bronchoscopy. Which of the following client statements indicates an understanding of the procedure? -----CORRECT ANSWER-----------b. "They will look into my lungs with a lighted tube to determine my problem. " A nurse is caring for a client who is in labor and has requested an alternative birthing plan. The client is experiencing back pain. Which of the following nursing actions is most effective? -----CORRECT ANSWER-----------a. Provide sacral counter pressure using the fist or ball of the hand. A nurse is caring for a postoperative client who has a midline abdominal incision and notes dehiscence of the wound edges with protrusion of internal organs. Which of the following actions should the nurse take? -----CORRECT ANSWER-----------b. Place pressure on the abdomen. d. Cover the wound with a sterile saline dressing. A nurse is collecting data from a client who is pregnant and has hypermesis gravidarum. Which of the following finding should the nurse expect? -----CORRECT ANSWER--------- --b. Decreased blood pressure. A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first? -----CORRECT ANSWER-----------b. Repeat the test on another finger. A nurse receives report on four clients. The nurse should first collect data about the client who has -----CORRECT ANSWER-----------b. a decreased level of consciousness and vomiting. A clinic nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? ----- CORRECT ANSWER-----------d. Urine protein 3+ A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. appropriate response. -----CORRECT ANSWER-----------b. you have the right to refuse the recommended treatment plan.