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A nurse in a pediatric unit is preparing to insert an IV catheter for a 7 year old. Which of the following actions should the nurse take?
Tell the child they will feel discomfort during catheter insertion.
A nurse is caring for a client who has arteriovenous fistula. Which of the following findings should the nurse report?
Absence of a bruit.
The nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?
I will wear loose clothing around my ICD.
A nurse is caring for a client who is 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
Describe your feelings to me about being pregnant.
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?
Administer a rectal suppository 30 minutes prior to scheduled defacation times.
Hba1c 10%
A nurse in a providers office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally modifiable infectious disease that should be reported to the state department of health?
Chlamydia
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
Use modeling to help the clients improve their interpersonal skills
A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) Passover holiday. Which of the following action should the nurse include in the plan of care?
Provide unleavened bread.
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment
The client reports feeling less anxious
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which ofthe following actions should the nurse do next.
Administer flumazenil to the client.
A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?
A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider?
WBC 14,000/mm
A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care. Which of the following information should the charge nurse include?
The proxy can make treatment decisions if the client is under anesthesia.
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
Turn the client on their side.
A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
Confirm the clients perception of the event.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take?
Document the clients condition every 15 minutes
A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
Place the client upright on a donut shaped cushion.
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply)
Tetanus diphtheria and acellular pertussis vaccine, Inactivated influenza vaccine
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian
A client who has gout and states, "I can continue to eat anchovies on my pizza."
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?
"I can give you information about respite care if you are interested."
A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in thechild's glucose. The nurse should identify this finding as an adverse effect of which of the following medications
Methylprednisolone.
The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching?
"You can increase your dietary intake of folic acid by eating cereals and citrus fruits".
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessmentsis the nurse's priority?
(Unable to read) (Picked this one) Medicaid? :(
Exhibit 1: Blood pressure: 102/56 mm Hg. Heart rate: 95/minRespiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2: Medication Administration RecordClozapine 150 mg PO twice dailyBenztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3:
Nurse's notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous.
Sore throat
A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel
An RN evaluates the client needs to determine tasks to delegate"
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
FHR baseline 170/min
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left- sidedhemiplegia the following actions is the nurse's priority?
Ensure that the client has a referral for physical therapy.
A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station?
A client who has depressive disorder and reports feeling hopeless.
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?
Administering potassium IV bolus
`A nurse is providing teaching for family members of a client who has dementia. Which of the following should the nurse include in the teaching?
Establish a toiling schedule for the client
The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives.Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives?
Thrombophlebitis
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The clientstates,"It's hard not to listen to the voices." Which of the following questions should the nurse ask the client?
What helps you ignore what you are hearing?
A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?
Applying elbow immobilizers of an infant receiving cleft lip injury.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
We should establish our roles in the initial session
A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the followingrequires intervention by the staff nurse?
Waits 2 minutes between suctions.
A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?
Use three pronged grounded plugs.
A nurse is providing care for a group of clients. Which of the following client's should the nurse identify as having the highest risk fordeveloping a pressure injury?
A client who has a T-tube following an open cholecystectomy.
A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops. Which of the following statements indicates an understanding of the teaching?
"I will place pressure on the corner of my eye after using he eye drops"
A nurse is providing teaching to a client who is at 14 weeks gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
Swelling of the face
A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make?
"I can give you information about making end of life decisions".
