NURS 407 Comprehensive Predictor F ( all answers CORRECTLY HIGHLIGHTED ) FOR HIGH SCORING GRADES

Document Content and Description Below

Bat b 1. A nurse is caring for a client who has compartment syndrome following the application of a tast to the leg. Which of the following.. nurse take? Check the client's pedal pulses Administer... a dose of antlemetic medication Position the client's leg above the level of the heart .Apply ice to the extremity 2. A nurse is preparing to administer levothyroxine 50 micrograms to a client .Aavailable levothyroxine 0.025 mg/tablet .How many table to the nurse administer per dose? 3. 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 Place a throw rug over electrical cords Encourag the client to avoid wearing shoes at home Mark the edges of the doorway to the house with tape Ensure that area rugs have rubber backs 4. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in response to the staff member's conduct. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) 2- Give the staff member a written earning about the behavior. 1- Verbally remind the staff member of the expected behavior changes. 4- Suspend the staff member from employment at the facility 5- Dismiss the staff member from employment at the facility. 3- Set up a meeting to speak with the staff member about the behavior. 5. A nurse is providing teaching to a client who has a multiple sclerosis . Which of the following statement should the nurse include Limit your daily intake of high fiber foods Establish a voiding schedule by urinating exercises every 4 hours Avoid exercises that increase your body temperatureWear an eye patch over one eye for an entire day before switching 6. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? Calculate the fluid replacement based on vital signs and urinary output Determine the location and depth of burns Administer antibiotics to prevent sepsis. Check the mouth for smooth and smoky breath 7. A nurse is caring for a client who has a pressure injury on the coccyx .Which of the following should indicateto the nurse that… a stage III pressure injury ? Bone is exposed within the wound Shough and eschar is present Subcutaneous fat is visible The skin is reddened and intact 8. (OJO) A newly licensed nurse is unsure if an assigned task is within their scope of practice. which of the following resources should the nurse consult? Written prescription from the provider Institutional policies and procedures Verbal direction from the nurse manager State Nurse Practice Act 9. A nurse is caring for a client who has a prescription for 1 unit of packed RBCS. Flve minutes after beginning the transfusion… with chills. After stopping the transfusion, which of the following actions should the nurse taket? Infuse 500 mL lactated Ringer's Iv. Adininister epinephrine subcutaneously. Document the reaction in the medical record. Place the blood bag in a biohazard bag before discarding 10. A Nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? Assigning a health care surrogate requires legal consultationA client must create a do not resuscitate order when completing advances directives. Advance directives cannot be changed once implemented. A health care surrogate makes health care decisions when the client is no longer able. 11. A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following Information should the nurse Limit Intake of nuts and legumes. Choose foods high in vitamin B12 Choose high-fat cheese as a meal substitute. Limit Intake of foods high in vitamin C 12. OJO A nurse in an emergency department is assesing a client with major depressive disorder. Which of t nurse take first? Exhibit Obtain the clients weight Administer ondansetron to the client for ma Obtain a blood glucose level Implement seizure precaution for the client 13. A nurse is assessing the grief response of a client whose child died 6 mONTHS age Which of the following client statement should.. the provider as an Indication of major depressive disorder? I am unable to feel any joy since my child died. I feel guilty because my child died I now that will be reunited with my child someday I am angry that my child died. 14. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? Participate in community drills and mock events. Vaccinate susceptible children and adults against smallpox Assess types, levels and scopes of disasters. Make quarantine preparations for those exposed to anthrax Rationale: Assess First 15. A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client? Peanut butter sandwich Oatmeal with butter Chicken noodle soup Celery sticks 16. A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents byherself. The nurse should document this as which of the following findings? Agnosia Projection Perseveration Confabulation 17. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. which of the following information should the nurse including in the teaching? You should eat hot foods to reduce your sense of fulness during a meal. While eating, you should drink liquids frequently. Lunch should be your largest meal of the day During meals, you should eat foods with a high-calorie content first 18. A nurse is caring for four clients on a medical-surgical unit For which of the following clients should the nurse complete a medication conciciliation ? A client who has a prescription for a gallbladder sonogram A client who transfers from a private room Into a semi-private room A client who received twice the prescribed dose of a medication A client who returns to the unit from the PACU following surgery 19. A nurse is Initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instruction should the nurse…the client ? Take your diuretic medication with your evening meal Decrease your intake of cranberry juice Pan to urinate every 3 hours while you are awake Limit your fluid Intake to 500 milliters per day. " 20. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Measure the client vital signs. D. Fill out an incident report. 21. A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The nurse should identity that which of the following statement by the client Indicates an understanding of the teaching? I will change the wrapping on my left leg once a day at home I Should avoid moving the joints in my left leg I might still experience the feeling of numbness and brigling in my leftI can elevate my left leg on a pillow while lying in bed. 22. A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the Following clients should the nurse report to the nurse ? A client who has a prescription for compression stockings and did not receive them A client who consumes all the food from their meal tray A client who requests assistance to use the bedside commode A client who requests to sit in the bedside chair while watching TV 23. A nurse is preparing to obtain a client signature on an informed consent form. Which of the following actions should the nurse… Notify the provider if the client has questions about the procedure Ask the client to explain his understanding of the procedure. Inform the client of his right to change his mind witness the client signing the informed consent form 24. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which of the following intervention should the nurse include in the plan ? Cover lesions with an occlusive dressing after applying a corticosteroid Discontinue ultraviolet light therapy If lesions itchy Scrub external lesions with a pumice stone Instruct the client to add rubbing alcohol to bath water. 25. A nurse is caring for a client who received a large amount of heparin IV in error. Which of the following laboratory should the nurse aPTT INR Ferritin level Albumin level 26. (OJO) A nurse in an emergency department is caring for a client following a motor vehicle crash . The client Glasgow coma scale,, following findings should the nurse expects? The client opens eyes to sound The client withdraws from pain. The client Is oriented times three The client is unable to obey commands27. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the client’s biopsy report while on the elevator. Which of the following actions should the nurse take? Report the information to the charge nurse review confidentiality policies with laboratory employees- would be the job of the Facility manager or someone who audits or teaches HIPAA stuff contact the laboratory manager regarding the situation - you are not high enough up the chain to do that Notify the facilities legal department - no need to go that far 28. (OJO)A nurse is assessing a client who has a prescription for hydrocodone PRN . Which of the following adverse effects should the nurse identify priority for withholding this medication and notifying the provider ? Constipation Hypotension Urinary retention Nausea 29. A nurse is performing initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat lost thro.. production? Place the newborns crib away from of on air went to perform the assessment Evaluate respirations by observing the newborn's uncovered chest for 1 min Perform the assessment inmediately after bith before removing amniotic fluid Cover the scale with a warmed blanket before weighing the baby. 30. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient centered care C. Evidence based practice.D. Informatics. 31. A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin a client. Which of should the nurse identify as being incompatible with warfarin? Propranolol Lisinopril Magnesium hydroxide Naproxen 32. A nurse is preparing to administer a blood transfusion to a client , Which of the following actions should the nurse take ? Use an IV catheter that is at least 24-gauge. Prime the tubing with 0.9% sodium chloride. Attach a single-line administration set. Use tubing that does not have a filter in the drip chamber 33. A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse should include that which of following medications can increase the effects of warfarin ? Nafcilin Vitamin K Oral contraceptives 34. A charge nurse is planning a staff education and competence session about operating newly acquired cardiac monitoring equipment. Which of the following actions should the nurse plan to take? (Select all that apply.) Caution staff that the equipment is complicated to use. Require a return demonstration using the equipment. Provide reinforcement of teaching until the skill is learned. Wait to offer feedback on staff use of the equipment until the end of the session. Identify the current level of staff knowledge about the equipment. 35. 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? Take a bubble bath after intercourse Void every 5 to 6 hr during the day Drink four 240 mL (8 oz) glasses of water each day. Wear loose-fitting underwear.36. A nurse is providing teaching to a client who is scheduled for radiation therapy to treat esophageal cancer. Which of the following the nurse make? Drink mostly clear liquids. "Use commercial mouthwashes to rinse your mouth. Soften foods with gravy and sauces Warm up foods before eating. 37. (OJO) A nurse is assessing a client who has heart failure and is prescribed a 2,000 m / 24 hr fluid restriction .Which of the following fluid should the nurse report to the provider? Watery stools of 400 ml in 8 hr Oral intake of 300 ml in 8 hr Urinary output of 420 ml in 8 hr Intravenous intake of 240 ml in 8 hr 38. A nurse is helping to prepare a client in the operating room prior to a surgical procedure. which of the following action should Leave the client's arms and legs uncovered until after the induction of anesthesia Remove the client eyeglasses upon arrival to the operating room Provide padding to the pressure point areas when positioning the client Minimize conversation with the client to reduce anxiety 39. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in response to the staff member’s conduct. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Give the staff member a written earning about the behavior. (3) Verbally remind the staff member of the expected behavior changes. (2) Suspend the staff member from work for several day employment at the facility. (4) Dismiss the staff member from employment at the facility. (5) Set up a meeting to speak with the staff member about the behavior. (1) 40. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the nurse does not speak the same language as the client. The client partner and a 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s information? Request a female translator interpreter through the facility Ask a student nurse who speaks the same language to translate Have the child translate Allow the clients child to translate 41. A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first?Calculate the fluid replacement based on vital signs and urinary output Determine the location and depth of burns Administer antibiotics prophylactically to prevent sepsis. Check the mouth for smooth and smoky breath 42. OJO A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hrintake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take first? Compare the client’s wight to the previous day. Reduce the client’s sodium intake. Encourage the client to change positions frequently. Administer furosemide to the client. 43. A nurse is caring for a school-age child who has sickie cell anemia and is in vaso-acclusive crisis. Which of the following action the nurse…. Increase oral fluid intake Promote active range of motion exercises Apply cold compresses to the affected areas Prepare for a transfusion of platelets 44. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use. 45. A nurse is assessing a client who is immediately post-operative following hip arthroplasty, which of the following considerations should the nurse take when positioning the client? A. Place the client’s heels directly against the bed mattress. B. Ensure that the client’s hips remain in an abducted position. C. Maintain the client in a supine position for the first 24 hr. after surgery. D. Flex the client’s hip up to 120° when sitting in a chair. 46. OJO P[access device .Which of the following …. the child's family member Indicates an understanding of the teaching? I can expect my child to resume playing sports within 48 hours "Twill replace the dressing in 24 hours with an occlusive dressing" If my child develops an elevated temperature. I will contact you " I should encourage a dally shower to keep the insertion site clean. 47. A nurse is caring for a client who wears glasses. Which of the following actions shouldthe nurse take? A. Store the glasses in a labeled case. B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 48. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? Remove the protective gown after leaving the client Wear a mask when changing the linens in the client’s room. Place the client in a room with negative air pressure Wear gloves when providing care to the client. 49. A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer? A. Calcium gluconate. B. Sodium bicarbonate. C. Potassium chloride. D. Sodium phosphate. 50. 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? A. Hyperthyroidism.B. Thrombophlebitis. C. Diverticulosis. D. Hypocalcemia. E. 51. A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 52. A nurse is assessing a client who is immediately post-operative following hip arthroplasty, which of the following considerations should the nurse take when positioning the client? A. Place the client’s heels directly against the bed mattress. B. Ensure that the client’s hips remain in an abducted position. C. Maintain the client in a supine position for the first 24 hr. after surgery. D. Flex the client’s hip up to 120° when sitting in a chair. 53. A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer? A. Calcium gluconate. B. Sodium bicarbonate. C. Potassium chloride. D. Sodium phosphate. 54. A nurse is caring for an adult client who has prescriptions for multiple medications. Which of the following (Unable to read) as an age-related change that increases the risk for adverse effects from this medication? A. Rapid gastric emptying. B. Prolonged medication half-life. C. Increased medication elimination. D. Decreased medication sensitivity. 55. (Ojo) A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take? A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice.B. Tell staff explain procedures to clients before obtaining informed consent. C. Instruct unit staff to share personal experiences to help clients make decisions. 56. A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse should include that which of the following medications can increase the effects of warfarin. Nafcillin Aspirin Vitamin k Oral contraceptives 57. 101. A nurse is consulting a pharmacological reference about medication compatibility prior to administering warfarin to a client. Which of the following medications should the nurse identify as being incompatible with warfarin? Propranolol Lisinopril Magnesium hydroxide Naprox… 58. A charge nurse is planning a staff education and competency session about operating newly acquired cardiac monitoring equal. Which of the following actions should the nurse plan? (Select all that apply.) Wait to offer feedback on staff use of the equipment until the end of the session Require a return demonstration using the equipment Caution staff that the equipment is complicated to use Provide reinforcement of teaching until the skill is learned Identify the current level os staff knowledge about the equipment 59. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a cerebrovascular accident. Which of the following actions by the nurse best promotes communications among staff caring for the client? Noting changes in the treatment plan in the client’s medical record Recording the client’s progress in the nurses’ notes Posting swallowing precautions at the head of the client’s bed Having interdisciplinary team meetings for the client on a regular basis 60.A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. Place the child in as supine position after the feeding. Charge the feeding bag and tubing every 3 days.Warm the formula in the microwave prior to administration. 61. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. nivel D. Constipation for 2 days. 62. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? E. Confront the nurse about the suspected alcohol use. F. Inform another nurse on the unit about the suspected alcohol use. G. Ask the nurse to finish administering medications and then go home. H. Notify the nursing manager about the suspected alcohol use. 63. A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing. 64. A nurse is evaluating the response to the plan of care for a client who is grieving the death of a partner. Which of the following nurse identify as indicating that the client is experiencing maladaptive grieving ? The client openly expresses anger when discussing the partner death The client has joined a support group The client reports having good and bed days The client reports feelings of guilt about the partner death 65. A nurse is helping to prepare a client in the operating room prior to a surgical procedure. Which of the following actions should the nurse take?Leave the client's arms and legs uncovered until after the induction of anesthesia. Remove the cent's eyeglasses upon to the operating room Provide padding to the pressure point areas when positioning the client Minimize conversation with the client to reduce anxiety 66. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse’s priority? A. Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist. 67. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. rate 5 a 40 units/L D. Erythrocyte sedimentation rate 75 mm/hr para los hombres 0 a 22 y las mujeres de o a 29 68. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side.69. A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol nurse take to assist the client… the nurse take to assist the client in maintaining self-control of the behavior? Provide the client with periods of alone time for reflection on their behavior Discuss strategies with the client to reduce alcohol consumption gradually Give positive feedback to the client for using adaptive coping strategies Have the client's partner assume responsibility for monitoring the clients alcohol intake 70. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? Arrange for an ethics committee meeting to address the family’s concerns. Support the family’s decision and initiate life-sustaining measures. Complete an incident report. Encourage the family to contact an attorney. 71. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? Store the glasses in a labeled case. Clean the glasses with hot water. Clean the glasses with a paper towel. Store the glasses on the bedside table. 72. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? A. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon73. A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. E. Place the client in a supine position while resting. F. Draw a troponin level every 4hr. G. Obtain a cardiac rehabilitation consultation. 74. 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? F. Hyperthyroidism.G. Thrombophlebitis. H. Diverticulosis. I. Hypocalcemia. 75. A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C. Determine the client’s preferences about postmortem care. D. Request a conference with the client’s family. 76. A nurse is providing teaching to a client who is scheduled for radiation therapy to treat esophageal cancer. Which of the following should the nurse make? Drink mostly clear liquids Use commercial mouthwashes to rinse your mouth Soften foods with gravy and sauces Warm up foods before eating 77. A nurse is assessing a client who has heart failure and is prescribed a 2,000 Ml/ hr fluid restriction. Which of the following fluids should the nurse report to the provider? Water stools of 400Ml in 8 hr Oral intake of 300 ml in 8 hr Urinary output of 420 ml in 8 hr Intravenous intake of 240 ml in 8 hr 78. A nurse is caring for a client who has colon cancer and is terminality III. The client states I can believe going to die .Which of the following statement should the nurse make? Tell me what is Important to you right now Your doctor will make sure you wont be in much pain I felt the same way you re feeling when my mother died It might be comforting to pray for spiritual assistance 79. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first ? Palpate the pulse distal to the cast Position the casted extremity on a pillow Place an ice pack over the cast Teach the client to keep the cast clean and dry 80. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, thenurse does not speak the same language as the client. The client partner and a 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s information? a. Request a female translator interpreter through the facility b. Ask a student nurse who speaks the same language to translate c. Have the child translate d. Allow the clients partner to translate 81. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 82. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 83. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen.84. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client’s mouth when he is ready to eat. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 85. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? Limit the client’s visitors to 30 min per day. Discard the client’s linens in a double bag. Discard the radioactive source in a biohazard bag Cleanse equipment before removal from the client room 86. A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the following actions by the client understanding … teaching ? Advances the affected leg first prior to the nonaffected leg Uses both crutches when advancing the affected leg Applies full weight on the affected side when advancing crutches Planes weight on the axilla when advancing crutches 87. A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the nurse does not speak the same language as the client. The client partner and a 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s information? Request a female translator interpreter through the facility Ask a student nurse who speaks the same language to translate Have the child translate Allow the clients child to translate 88. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin? A. Diabetes mellitus.Shoulder presentation. Post term withhydramnios. Chorioamnionitis 89. A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in response to the staff members conduct Give the staff member a writing warning about the behavior Verbally remind the staff member of the expected behavior changes Suspend the staff member from work for several days Dismiss the staff member from employment at the facility Set up a meeting to speak with the staff member about the behavior 90. A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? Applying a sterile gown after applying a sterile mask Balancing the bottle on the sterile basin while pouring the liquid Placing the supplies on the sterile filed and leaving a 1- inch perimeter Putting on sterile gloves after preparing the sterile field 91. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D..Bradypnea92. A nurse is obtaining a clients manual blood pressure and is having difficulty auscultating sounds .Which of the following actions should the nurse …? Use the palpatory method to determine biood pressure Deflate the cuff quickly . Place the arm above the level of the client's heart Apply the largest cuff available. 93. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? A. “Your baby needs an IV because she is not producing any tears” B. “Your baby needs an IV because her fontanels are budging” C. “Your baby needs an IV because she is breathing slower than normal” D. “Your baby needs an IV because her heart rate is decreasing” 94. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. “Taking furosemide can cause your potassium levels to be high” B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 95. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors 96. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesiaPseudo parkinsonism. C. Acute dystonia. 97. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D.Stand within 30 cm (1 ft) of the client when speaking with them. 98. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? E. “Taking furosemide can cause your potassium levels to be high” F. “Eat foods that are high in sodium” G. “Rise slowly when getting out of bed” H. “Taking furosemide can cause you to be overhydrated” 99. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors 100. A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? D. Serotonin syndrome E. Tardive dyskinesia Pseudo parkinsonism. F. Acute dystonia.101. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. C. Express sympathy for the client’s situation. C. Speak assertively to the client. D.Stand within 30 cm (1 ft) of the client when speaking with them.102. A nurse is calculating a client's expected date of delivery. The clients fast menstral period began April 12 Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. ( C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 103. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching? UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 104. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Apply pressure to the lacrimal punctum.5 2. Ask the child to look upward. 2 3. Pull the lower eyelid downward. 3 4. Instill the drops of medication. 4 5. Place the child in a sitting position. 1105. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. 106. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. A. Montevideo units constantly 300 mm Hg. B. FHR pattern with absent variability. C. Contractions every 5 min that last 30 seconds. 107. A nurse is planning care for a group of clients and is working with one licensed practical nurse LPN and one assistive personal AP. Which of the following actions should the nurse take first to manage her time effectively? Develop an hourly time frame for tasks Schedule daily activities Determine goals of the day Delegate tasks to the AP 108. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs.D. Providing crisis intervention through a mobile counseling unit. 109. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 110. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. Dyspnea. Hypotension. Thready pulse. 111. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? I. “The PCA will deliver a double dose of medication when you push the button twice.” J. “You can adjust the amount of pain medication you receive by pushing on the keypad.” K. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” L. “You should push the button before physical activity to allow maximum pain control.” 112. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? E. Match the client’s blood type with the type and cross match specimens. F. Confirm the provider’s prescription matches the number on the blood component. G. Ask the client to state the blood type and the date of their last blood donation. H. Ensure that the client’s identification band matches the number on the blood unit. 113. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? B. “I noticed that I am having a harder time holding on to my toothbrush”C. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” D. “Sometimes, I feel I am making a chewing motion when I’m not eating” 114. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 115. 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? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord. 116. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. E. A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG 117. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? 137 “I recommend that you take this medication as prescribed”138 “Do you know why this medication is being prescribed to you?” 139 “I will call the pharmacist now to check on this medication” Did the doctor discuss with you that there was a change in this medication 118. A community health nurse is developing a plan to improve the communitys environmental health. which of the following action nurse take first? Establish a timeframe for environmental improvements. Encourage community Involvement in environmental improvement Request funding from community organizations Collect information about the community's environmental status 119. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? E. Withhold the next dose.F. Increase the dosage. G. Discontinue the medication. H. Administer the medication. 120. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the nurse report to the provider? Pulse 140/min Closed anterior fontanel Respiratory rate 26/min Abdominal breathing 121. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? Place copies of incident reports in client’s medical records Overestimate clients acuilty to prevent short staffing Ensure that each client has a living will on file prior to treatment Obtain personal professional liability insurance coverage 122. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following Interventions should the nurse Include in the plan of care? Screen the child's visitors for active Infections. Initiate Prepare the child for a platelet transfusion. Prepare the child for a platelet transfusion. Monitor the child for indications of active bleeding123. A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement and the nurse offers a bed pan. The client states. “I’ve always used the bathroom. “Which of the following responses should the nurse make? “Tell me what concerns you have about using a bed pan.” “I will have the physical therapist ambulate you to the bathroom.” “You have to use the bed pan for you own safety.” “Make sure to use nearby furniture to support yourself when walking to the bathroom. 124. A newly licensed nurse is unsure if an assigned task is within their scope of practice. which of the following resources should the nurse consult? Written prescription from the provider Institutional policies and procedures Verbal direction from the nurse manager State Nurse Practice Act 125. A Nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? Assigning a health care surrogate requires legal consultation A client must create a do not resuscitate order when completing advances directives. Advance directives cannot be changed once implemented. A health care surrogate makes health care decisions when the client is no longer able. 126. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? I. “Staff will apply identification band after first bath” J. “I will not publish public announcement about my baby’s birth” K. “I can remove my baby’s identification band as long as she is in my room” L. “I can leave my baby in my room while I walk in the hallway” 127. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse should identity that which of the following client for fluid volume excess? A client who has ulcerative colitis A client who has an exacerbation of peptic ulcer disease A client who has diabetes insipidus A client who has advanced stage liver cirrhosis 128. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube The high pressure alarmis beeping and the.. experiencing respiratory distress. the nurse is unable to determine the cause pf the alarm. Which of the following actions should the nurse … Deliver breaths manually with a resuscitation bag Decrease the ventilation flow rate Reevaluate the client for an ET cuff leak Assess for disconnected tubing129. A nurse on a mental health unit is admitting a client who has posttraumatic stress, disorder.Which of the following should the nurse expect ? Experiences frequent grandiose thoughts Talks continuously about the event has difficulty concentrating on a task Preoccupled with having a serious illness 130. A nurse is verifying a record of informed consent for a client who is sheduled for surgery .Which of the following actions should the nurse ….? Inform the client about the condition that requires teatment Confirm the client's signature Is authentic Explain the procedure to the client before verifying informed Provide Information on the informed consent form about the benefits of the surgery 131. 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? We can provide a copy of your records, but the therapists notes are not included I don’t think you will benefit from reviewing your therapists notes right now Why are you interested in seeing your therapist’s notes? Are you not happy with your treatment? 132. A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse should instruct the family members…of the following foods can cause an interaction with this medication ? Cottage cheese loeberg lettuce salad bologna sandwich Orange gelatin 133. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse should identify that which of the following … altered tissue perfusion of the affected extremity ? Faint pedal pulse of left leg Warm sidn temperature distal to pin site Pain with movement of the left great toe Purulent drainage at the pin site 134. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should the nurse identify as indicating the client experiencing mania ? The client speaks using echopraxia The client speaks using word salad. The client is easily distracted by external stimuli The client is socially withdrawn135. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary catheter for three days. Which of the following action should the nurse take after collecting the specimens? Remove gloves after labeling the specimen Place the specimen in a biohazard bag for transport Obtain the specimen from the drainage collection bag Wipe the outside of the specimen container with alcohol 136. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? M. Looking at alphabet flashcards. N. Playing with a large plastic truck. O. Use scissors cut out paper shapes. P. Watching a cartoon in the dayroom. 137. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication ventricular tachycardia? P wave present with every QRS complex Sowtooth shaped P waves PR interval of 0.24 seconds QRS complexes wider than 0.15 seconds 138. 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 the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? Inform the transferring agency of the client’s condition. Privately interview the client about her condition. Notify risk management Contact the family regarding the client’s condition. 139. community health nurse is reviewing laboratory reports for a group of client. The nurse should identify that which of the following disorder on the CDC's Nationally Notifiable Conditions list! Bacterial vaginosis Lyme disease Respiratory syncytial virus Pediculosis capitis 140. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct in her diet to prevent a neural tube defect? Folate Zinc Iron Calcium 141. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the followingmanifestations should the nurse expect? Loose stools Jitteriness Hypertonia Abdominal distention 142. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer? Omeprazole Ketorolac Acetaminophen Metoclopramide 143. A nurse is giving an intramuscular injection to a newborn who has delivered at 38 weeks of gestation .Which of the following pain scale should the nurse use to assess the newborn pain ? FACE pain rating scale Premature Infant Pain Profile (PIPP) Visual analog scale (VAS) Neonatal Infant Pain Scale (NIPS) 144. A nurse is admitting a client who does not speak the same language as the nurse and scheduled for outpatient surgery. Which of following actions should the nurse take? Request a family member to interpret the information. Explain the procedure to the client through an interpreter. Provide consent form that is written in the client’s own language. Help the client look up the information about the procedure on the internet 145. A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take ? Clean the site using vigorous friction Apply a tourniquet firmly above the insertion Use 22-gauge catheter for insertion Select a vein on the back of the hand 146. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? Pregabalin Lorazepam Colchicine Codeine 147. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach Ieat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 148. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? Phlebitis Abdominal aortic aneurysm Osteoarthritis Peripheral neuropathy 149. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following information should the nurse include about preventing the spread infection? Clean blood contaminated surfaces with bleach. Use condoms with a petroleum-based lubricant. Wash soiled clothes in cold water. Buy disposable dishes for daily use. 150. A nurse is caring for a client who is receiving continuous enteral feedings. which of the following actions should the nurse take? Select Check placement of the feeding tube by x-ray once daily Maintain the head of the client's bed at a30% angle or higher Check gastric residuals every 4 hr. Change the feeding container and tubing every 24 hr. Ensure the formula is cold before administration 151. A nurse is assessing a client who has bipolar disorder and is experiencing depressive episode. which of the following findings should the nurse expect? Clent expresses ilusions of grandeur Inability to carry out a simple task Client reports auditory hallucinations Moves quickly from one idea to the next 152. A nurse is caring for a client who is postoperative immediately following a cardiac catheterizacion with a right femoral appro..Which of the following actions should the nurse take? Elevate the head of the client's bed to 45 Assess the client's peripheral pulses every 15 min. Change the client's dressing 4 hr following the procedure. Instruct the client to flex the right knee every 30 min. 153. A nurse is teaching a client who has chronic low back pain about the use of alternative therapy to manage pain. Which of the following by the client indicates an understanding of the use of distraction? I will have electrodes inserted in my skin to treat the pain I should apply my heating blanket to my back to reduce tension I should jog every morning to improve my circulationI will watch my favorite old movies when I want to reduce stress 154. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse should include in the teaching that which obtains she lowest amount of saturated fats ? Coconut oil Olive oil Canola oil Palm oil 155. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse referral to a dietitian? An older adult client who has a BMI of 24 A client who has a nonhealing leg ulcer An older adult client who has presbyopia A client who has an albumin level of 3.7g/Dl 156. A nurse is teaching a childbirth education class and is discussing sexual intercourse during pregnancy. Which of the following statements should the nurse make? “The female superior position can be used during the third trimester of pregnancy.” “Frequent intercourse increases the risk for miscarriage in early pregnancy.” “You should limit the frequency of intercourse after weeks of pregnancy.” Your sexual desire might increase during the first trimester of pregnancy.” 157. A nurse is caring for an older adult client in a long-term care facility, recently lab values shows increased hemoglobin, hematocrit, and urine irregularity which findings suggest anemia Anemia. Dehydration Hepatic failure Acute renal failure 158. 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? Take a bubble bath after intercourse Void every 5 to 6 hr during the day Drink four 240 mL (8 oz) glasses of water each day. Wear loose-fitting underwear. 159. A charge nurse is planning a staff education and competence session about operating newly acquired cardiac monitoring equipment. Which of the following actions should the nurse plan to take? (Select all that apply.) Caution staff that the equipment is complicated to use. Require a return demonstration using the equipment. Provide reinforcement of teaching until the skill is learned. Wait to offer feedback on staff use of the equipment until the end of the session. Identify the current level of staff knowledge about the equipment.160. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? G. “Dehydration is treated with calcium supplements” H. “Dehydration can increase the risk of preterm labor” I. “Dehydration associated gastroesophageal reflux J. “Dehydration is caused by a decreased hemoglobin and hematocrit” 161. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED Hgb 12.8 g/dl - 12- 16 Potassium 4.2 meq/l 3.5 - 5.0 meq RBC 4.4 million/mm3 Platelets 100,000/mm3 162. A nurse is caring for a client who tells the nurse that he feels he is being discharged from the facility too soon .which of the following the nurse demonstrate client advocacy? I will contact your insurance company to see if they will pay for you to be have longer? Your provider understands your illness and is acting according to your best interests I will that the provider about your concerns I know you will be able to recover faster at home 163. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the following statements by a client indicated an understanding of the teaching? “I will consume 48 ounces of carbonated beverages daily prior to the surgery.” “I will need to lose 25 percent of my excess body weight prior to surgery.” “I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after surgery.” “I should wait 30 minutes after eating solid foods to drink beverages following surgery.” 164. A nurse is caring for several clients on a medical-surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves? Inserting an NG tube Administering total parenteral nutritional through a central venous access device Initiating IV access Performing tracheostomy care 165. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statements by the client indicates an understanding of the teaching? “I can begin to drive 24 hours after surgery.”“I can shower within 48 hours of my surgery.” “I will have my drains removed 1 hour prior to going home.” ‘I will complete my arm exercises four times a day.” 166. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? “I should apply power to my skin after showering.” “I will not able to go for my daily walk.” “I will cleanse my skin using a mild soap.” “I should check my skin once weekly for rashes.” 167. A nurse is providing discharge teaching to a female client who has tuberculosis and a new prescription for rifampin. Which of the following information should the nurse include? “Your urine will be orange while this medication.” Weight gain is an expected adverse effect of this medication You should avoid getting pregnant for 6 months after stooping this medication You should avoid sun exposure while taking this medication 168. A nurse is providing discharge Instructions to a client who has a new prescription for spironolactone .Which of the following the nurse include in the teaching? Monitor weight once a week Take the medication in the morning Use a salt substitute with meals Administer a potassium supplement daily 169. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following prescriptions should the nurse expect the provider to prescribe? Atorvastatin Amoxicillin Enoxaparin Interferon beta-1a 170. 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? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 171. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.) A client who describes having persistent feelings of anger about the hurricane. A client who has frequent nightmares about the hurricane. A client who expresses a realization that life will not return to the way it was before the hurricane.A client who moved to an apartment located on higher ground than her previous home. A client who describes feeling disconnected from those around him following the hurricane. 172. A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The nurse should monitor for which of the following finding as an adverse effect of the radiation? Excessive salivation Insomnia Altered sensation Elevate platelet count 173. A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include? Wear a tight-fitting underwire bra. Apply warm compresses on the breasts before feedings. Allow the infant to nurse on one breast per feeding. Take aspirin to reduce pain and swelling. 174. A nurse is a community clinic is caring for client who request assistant with smoking censation The nurse should expect a prescription for which of the following medications? Bupropion Chiordiazepoxide Naltrexone Clonidine 175. A nurse is preparing to administer an IV medication to a client and accidently 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 biohazardous material spill? Doxorubicin hydrochloride Ampicillin sodium Metronidazole Phenytoin 107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? Obtain the newborn’s body temperature using a tympanic thermometer. Assess the newborn pain level using FACES pain scale. Auscultate the newborn’s apical pulse for 60 seconds. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. 108. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?“Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3 mg Subcutaneous every 4 hr PRN for pain “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” “Morphine 3 mg SC q 4 hr. PRN for pain.” 109. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the medications? Calcium gluconate Sodium bicarbonate. Potassium chloride. Magnesium citrate 110. A nurse is reviewing the formulary about NPH insulin before administering the medication to a client. Which of the following information the nurse expect ? Administrer NPH Insulin 30min before breakfast. Give NPH Insulin by IV bolus Use NPH insulin to treat ketoacidosis Discard the NPH insulin vial if the medication is cloudy 111. A nurse is planning care for a school age child who is 4 hr postoperative following appendicitis .Which of the following action should the nurse include in the plan of care ? Administer analgesics on a scheduled basis for the first 24 hr Apply a warm compress to the operative site once daily Offer small amounts of dear liquids 6 hr following surgery Give cromolyn nebulized solution every8 hr 112. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the fetal well being due to potencial preterm labor following places of equipment should the nurse use to evaluate the fetal heart rate? Intrauterine pressure catheter Spiral electrode Toco transducer ultrasound transducer 113. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer. Which of the following findings should the nurse identify as a contributing factor? The client takes prednisone for arthritis. The client is receiving IV dextrose 5% in water at 100 mL/hr. The client has a total cholesterol level of 190 mg/dL. The client has an albumin level of 3.8 g/dL 114. A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The nurse should monitor for which of the following adverse effects? Hypoglycemia Hypokalemia Euphoria Increased intraocular pressure 115. A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include?Change smoke detector batteries every other year. Lay the baby on his stomach to nap during the daytime. Use a car seat when traveling by airplane Place a plastic waterproof sheet over the crib bedding. 116. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass surgery .which of the following finding should the nurse impact in the affected extremity? Cool extremities Pedal pulse of 2+ Throbbing pain Capillary refill of 4 seconds 117. A home health nurse is teaching a new parent about caring for his 1-week-old-infant. Which of the following statements by the client indicates an understanding of the teaching? “I can use a form pillow to prop up the bottle when feeding my baby.” “I will avoid picking up my baby too often to keep from spoiling him.” “I will hang a pastel-colored mobile 24 inches above my baby’s crib.” “I will place a ticking clock nearly to soothe my baby throughout the day.” 118. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? Apply zinc oxide ointment to the irritated area. Wipe stool from the skin using store bought baby wipes. Wipe urine from the skin using a cool cloth Apply talcum powder to the irritable area 119. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should identify that which of the following allergic reaction to this medication ? Difficulty swallowing Blurred vision Weight gain High blood pressure 120. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? Place the tip of the thermometer under the center of the infant’s axilla. Pull the pinna of the infant’s ear forward before inserting the probe. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. Insert the thermometer in front of the infant’s tongue. 121. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? Q. Coffee with creamer. R. Lettuce with sliced avocados. S. Broiled skinless chicken breast with brown rice.T. Warm toast with margarine. 122. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 123. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? Chest pain Muscle spasms. Cool, moist skin. Incisional pain. 124. A nurse is providing teaching to a client who is to begin external radiation therapy for cancer .Which of the following information include ? Wash your skin thoroughly with a washcloth after each treatment Wear a binder over the radiation site You might experience altered taste sensations Use rubbing alcohol to remove the ink maricings 125. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following intervention should the nurse take ? Suction nares prior to feeding Request a prescription for guaifenesin Administer palivizumab intravenously Initiate neutropenic precautions 126. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? “Can you talk about what happens with your partner at home?” “Why do you think your partner’s symptoms are progressing so quickly?” “You should make sure your partner takes the prescribed medication.” “You did the right thing by bringing your partner in for treatment.” 127. A nurse in a provider’s 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 notifiable infectious disease that should be reported to the state health department?A. Chlamydia B. Human papillomavirus C. Candidiasis D. Herps simplex virus 128. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? The client’s parent is in a skilled nursing facility The client is allergic to penicillin The client has two small children at home The client lives in a two-story home 129. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hr-intake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take first? Compare the client’s wight to the previous day. Reduce the client’s sodium intake. Encourage the client to change positions frequently. Administer furosemide to the client. 130. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months A client who will be receiving her first ECT treatment today A client placed in restraints due to aggressive behavior A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety 131. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. which of the following actions should the nurse take Decrense the lighting levels in the nursery Wrap the newborn loosely in a bianket Encourase frequent eye contact with the newborn during feeding Provide frequent stimulation for the newborn176. A nurse is calculating a client's expected date of delivery. The clients fast menstral period began April 12 Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. ( C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 177. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching? UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” E. “Given 2 mg MSO4 IM for report of pain” F. “Dressing changed qd” G. “Administered 8 u regular insulin sq.” 178. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 6. Apply pressure to the lacrimal punctum.5 7. Ask the child to look upward. 2 8. Pull the lower eyelid downward. 3 9. Instill the drops of medication. 4 10. Place the child in a sitting position. 1179. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? E. Request an interpreter of a different sex from the client. F. Request a family member or friend to interpret information for the client. G. Direct attention toward the interpreter when speaking to the client. H. Review the facility policy about the use of an interpreter. 180. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. D. Montevideo units constantly 300 mm Hg. E. FHR pattern with absent variability. F. Contractions every 5 min that last 30 seconds. 181. A nurse is planning care for a group of clients and is working with one licensed practical nurse LPN and one assistive personal AP. Which of the following actions should the nurse take first to manage her time effectively? Develop an hourly time frame for tasks Schedule daily activities Determine goals of the day Delegate tasks to the AP 182. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. C. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs.D. Providing crisis intervention through a mobile counseling unit. 183. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. “I will take sucralfate with meals three times per day” b. “I will avoid food and beverages that contain caffeine” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 184. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. Dyspnea. Hypotension. Thready pulse. 185. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? U. “The PCA will deliver a double dose of medication when you push the button twice.” V. “You can adjust the amount of pain medication you receive by pushing on the keypad.” W. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” X. “You should push the button before physical activity to allow maximum pain control.” 186. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? M.Match the client’s blood type with the type and cross match specimens. N. Confirm the provider’s prescription matches the number on the blood component. O. Ask the client to state the blood type and the date of their last blood donation. P. Ensure that the client’s identification band matches the number on the blood unit. 187. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? E. “I noticed that I am having a harder time holding on to my toothbrush”F. “Lately, I feel like my feet are freezing up, as they are stuck to the ground” G. “Sometimes, I feel I am making a chewing motion when I’m not eating” 188. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 189. 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? I. Use three pronged grounded plugs. J. Cover extension cords with a rug. K. Check the tingling sensations around the cord to ensure the electricity is working. L. Remove the plug from the socket by pulling the cord. 190. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? F. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. G. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. H. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. I. A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG 191. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? 140 “I recommend that you take this medication as prescribed”141 “Do you know why this medication is being prescribed to you?” 142 “I will call the pharmacist now to check on this medication” Did the doctor discuss with you that there was a change in this medication 192. A community health nurse is developing a plan to improve the communitys environmental health. which of the following action nurse take first? Establish a timeframe for environmental improvements. Encourage community Involvement in environmental improvement Request funding from community organizations Collect information about the community's environmental status 193. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? M. Withhold the next dose.N. Increase the dosage. O. Discontinue the medication. P. Administer the medication. 194. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the nurse report to the provider? Pulse 140/min Closed anterior fontanel Respiratory rate 26/min Abdominal breathing 195. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? Place copies of incident reports in client’s medical records Overestimate clients acuilty to prevent short staffing Ensure that each client has a living will on file prior to treatment Obtain personal professional liability insurance coverage 196. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following Interventions should the nurse Include in the plan of care? Screen the child's visitors for active Infections. Initiate Prepare the child for a platelet transfusion. Prepare the child for a platelet transfusion. Monitor the child for indications of active bleeding197. A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement and the nurse offers a bed pan. The client states. “I’ve always used the bathroom. “Which of the following responses should the nurse make? “Tell me what concerns you have about using a bed pan.” “I will have the physical therapist ambulate you to the bathroom.” “You have to use the bed pan for you own safety.” “Make sure to use nearby furniture to support yourself when walking to the bathroom. 198. A newly licensed nurse is unsure if an assigned task is within their scope of practice. which of the following resources should the nurse consult? Written prescription from the provider Institutional policies and procedures Verbal direction from the nurse manager State Nurse Practice Act 199. A Nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching? Assigning a health care surrogate requires legal consultation A client must create a do not resuscitate order when completing advances directives. Advance directives cannot be changed once implemented. A health care surrogate makes health care decisions when the client is no longer able. 200. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? Q. “Staff will apply identification band after first bath” R. “I will not publish public announcement about my baby’s birth” S. “I can remove my baby’s identification band as long as she is in my room” T. “I can leave my baby in my room while I walk in the hallway” 201. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse should identity that which of the following client for fluid volume excess? A client who has ulcerative colitis A client who has an exacerbation of peptic ulcer disease A client who has diabetes insipidus A client who has advanced stage liver cirrhosis 202. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube The high pressure alarmis beeping and the.. experiencing respiratory distress. the nurse is unable to determine the cause pf the alarm. Which of the following actions should the nurse … Deliver breaths manually with a resuscitation bagDecrease the ventilation flow rate Reevaluate the client for an ET cuff leak Assess for disconnected tubing 203. A nurse on a mental health unit is admitting a client who has posttraumatic stress, disorder.Which of the following should the nurse expect ? Experiences frequent grandiose thoughts Talks continuously about the event has difficulty concentrating on a task Preoccupled with having a serious illness 204. A nurse is verifying a record of informed consent for a client who is sheduled for surgery .Which of the following actions should the nurse ….? Inform the client about the condition that requires teatment Confirm the client's signature Is authentic Explain the procedure to the client before verifying informed Provide Information on the informed consent form about the benefits of the surgery 205. 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? We can provide a copy of your records, but the therapists notes are not included I don’t think you will benefit from reviewing your therapists notes right now Why are you interested in seeing your therapist’s notes? Are you not happy with your treatment? 206. A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse should instruct the family members…of the following foods can cause an interaction with this medication ? Cottage cheese loeberg lettuce salad bologna sandwich Orange gelatin 207. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse should identify that which of the following … altered tissue perfusion of the affected extremity ? Faint pedal pulse of left leg Warm sidn temperature distal to pin site Pain with movement of the left great toe Purulent drainage at the pin site 208. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should the nurse identify as indicating the client experiencing mania ?The client speaks using echopraxia The client speaks using word salad. The client is easily distracted by external stimuli The client is socially withdrawn 209. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary catheter for three days. Which of the following action should the nurse take after collecting the specimens? Remove gloves after labeling the specimen Place the specimen in a biohazard bag for transport Obtain the specimen from the drainage collection bag Wipe the outside of the specimen container with alcohol 210. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? Y. Looking at alphabet flashcards. Z. Playing with a large plastic truck. AA.Use scissors cut out paper shapes. BB. Watching a cartoon in the dayroom. 211. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication ventricular tachycardia? P wave present with every QRS complex Sowtooth shaped P waves PR interval of 0.24 seconds QRS complexes wider than 0.15 seconds 212. 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 the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? Inform the transferring agency of the client’s condition. Privately interview the client about her condition. Notify risk management Contact the family regarding the client’s condition. 213. community health nurse is reviewing laboratory reports for a group of client. The nurse should identify that which of the following disorder on the CDC's Nationally Notifiable Conditions list! Bacterial vaginosis Lyme disease Respiratory syncytial virus Pediculosis capitis 214. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct in her diet to prevent a neural tube defect? FolateZinc Iron Calcium 215. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect? Loose stools Jitteriness Hypertonia Abdominal distention 216. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer? Omeprazole Ketorolac Acetaminophen Metoclopramide 217. A nurse is giving an intramuscular injection to a newborn who has delivered at 38 weeks of gestation .Which of the following pain scale should the nurse use to assess the newborn pain ? FACE pain rating scale Premature Infant Pain Profile (PIPP) Visual analog scale (VAS) Neonatal Infant Pain Scale (NIPS) 218. A nurse is admitting a client who does not speak the same language as the nurse and scheduled for outpatient surgery. Which of following actions should the nurse take? Request a family member to interpret the information. Explain the procedure to the client through an interpreter. Provide consent form that is written in the client’s own language. Help the client look up the information about the procedure on the internet 219. A nurse is preparing to initiate IV therapy for an older adult client. Which of the following actions should the nurse plan to take ? Clean the site using vigorous friction Apply a tourniquet firmly above the insertion Use 22-gauge catheter for insertion Select a vein on the back of the hand 220. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? Pregabalin Lorazepam ColchicineCodeine 221. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian E. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. F. A client who has gout and states, “I can continue to eat anchovies on my pizza.” G. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. H. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 222. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? Phlebitis Abdominal aortic aneurysm Osteoarthritis Peripheral neuropathy 223. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following information should the nurse include about preventing the spread infection? Clean blood contaminated surfaces with bleach. Use condoms with a petroleum-based lubricant. Wash soiled clothes in cold water. Buy disposable dishes for daily use. 224. A nurse is caring for a client who is receiving continuous enteral feedings. which of the following actions should the nurse take? Select Check placement of the feeding tube by x-ray once daily Maintain the head of the client's bed at a30% angle or higher Check gastric residuals every 4 hr. Change the feeding container and tubing every 24 hr. Ensure the formula is cold before administration 225. A nurse is assessing a client who has bipolar disorder and is experiencing depressive episode. which of the following findings should the nurse expect? Clent expresses ilusions of grandeur Inability to carry out a simple task Client reports auditory hallucinations Moves quickly from one idea to the next 226. A nurse is caring for a client who is postoperative immediately following a cardiac catheterizacion with a right femoral appro..Which of the following actions should the nurse take? Elevate the head of the client's bed to 45 Assess the client's peripheral pulses every 15 min.Change the client's dressing 4 hr following the procedure. Instruct the client to flex the right knee every 30 min. 227. A nurse is teaching a client who has chronic low back pain about the use of alternative therapy to manage pain. Which of the following by the client indicates an understanding of the use of distraction? I will have electrodes inserted in my skin to treat the pain I should apply my heating blanket to my back to reduce tension I should jog every morning to improve my circulation I will watch my favorite old movies when I want to reduce stress 228. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse should include in the teaching that which obtains she lowest amount of saturated fats ? Coconut oil Olive oil Canola oil Palm oil 229. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse referral to a dietitian? An older adult client who has a BMI of 24 A client who has a nonhealing leg ulcer An older adult client who has presbyopia A client who has an albumin level of 3.7g/Dl 230. A nurse is teaching a childbirth education class and is discussing sexual intercourse during pregnancy. Which of the following statements should the nurse make? “The female superior position can be used during the third trimester of pregnancy.” “Frequent intercourse increases the risk for miscarriage in early pregnancy.” “You should limit the frequency of intercourse after weeks of pregnancy.” Your sexual desire might increase during the first trimester of pregnancy.” 231. A nurse is caring for an older adult client in a long-term care facility, recently lab values shows increased hemoglobin, hematocrit, and urine irregularity which findings suggest anemia Anemia. Dehydration Hepatic failure Acute renal failure 232. 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? Take a bubble bath after intercourse Void every 5 to 6 hr during the day Drink four 240 mL (8 oz) glasses of water each day.Wear loose-fitting underwear. 233. A charge nurse is planning a staff education and competence session about operating newly acquired cardiac monitoring equipment. Which of the following actions should the nurse plan to take? (Select all that apply.) Caution staff that the equipment is complicated to use. Require a return demonstration using the equipment. Provide reinforcement of teaching until the skill is learned. Wait to offer feedback on staff use of the equipment until the end of the session. Identify the current level of staff knowledge about the equipment. 234. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? K. “Dehydration is treated with calcium supplements” L. “Dehydration can increase the risk of preterm labor” M.“Dehydration associated gastroesophageal reflux N. “Dehydration is caused by a decreased hemoglobin and hematocrit” 235. A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? CONFIRMED Hgb 12.8 g/dl - 12- 16 Potassium 4.2 meq/l 3.5 - 5.0 meq RBC 4.4 million/mm3 Platelets 100,000/mm3 236. A nurse is caring for a client who tells the nurse that he feels he is being discharged from the facility too soon .which of the following the nurse demonstrate client advocacy? I will contact your insurance company to see if they will pay for you to be have longer? Your provider understands your illness and is acting according to your best interests I will that the provider about your concerns I know you will be able to recover faster at home 237. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the following statements by a client indicated an understanding of the teaching? “I will consume 48 ounces of carbonated beverages daily prior to the surgery.” “I will need to lose 25 percent of my excess body weight prior to surgery.” “I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after surgery.” “I should wait 30 minutes after eating solid foods to drink beverages following surgery.”238. A nurse is caring for several clients on a medical-surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves? Inserting an NG tube Administering total parenteral nutritional through a central venous access device Initiating IV access Performing tracheostomy care 239. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statements by the client indicates an understanding of the teaching? “I can begin to drive 24 hours after surgery.” “I can shower within 48 hours of my surgery.” “I will have my drains removed 1 hour prior to going home.” ‘I will complete my arm exercises four times a day.” 240. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? “I should apply power to my skin after showering.” “I will not able to go for my daily walk.” “I will cleanse my skin using a mild soap.” “I should check my skin once weekly for rashes.” 241. A nurse is providing discharge teaching to a female client who has tuberculosis and a new prescription for rifampin. Which of the following information should the nurse include? “Your urine will be orange while this medication.” Weight gain is an expected adverse effect of this medication You should avoid getting pregnant for 6 months after stooping this medication You should avoid sun exposure while taking this medication 242. A nurse is providing discharge Instructions to a client who has a new prescription for spironolactone .Which of the following the nurse include in the teaching? Monitor weight once a week Take the medication in the morning Use a salt substitute with meals Administer a potassium supplement daily 243. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the following prescriptions should the nurse expect the provider to prescribe? Atorvastatin Amoxicillin Enoxaparin Interferon beta-1a 244. A nurse is caring for a client who has a history of depression and is experiencing asituational crisis. Which of the following actions should the nurse take first? A. Confirm the client’s perception of the event B. Notify the client’s support system C. Help the client identify personal strengths D. Teach the client relaxation techniques 245. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.) A client who describes having persistent feelings of anger about the hurricane. A client who has frequent nightmares about the hurricane. A client who expresses a realization that life will not return to the way it was before the hurricane. A client who moved to an apartment located on higher ground than her previous home. A client who describes feeling disconnected from those around him following the hurricane. 246. A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The nurse should monitor for which of the following finding as an adverse effect of the radiation? Excessive salivation Insomnia Altered sensation Elevate platelet count 247. A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include? Wear a tight-fitting underwire bra. Apply warm compresses on the breasts before feedings. Allow the infant to nurse on one breast per feeding. Take aspirin to reduce pain and swelling. 248. A nurse is a community clinic is caring for client who request assistant with smoking censation The nurse should expect a prescription for which of the following medications? Bupropion Chiordiazepoxide Naltrexone Clonidine 249. A nurse is preparing to administer an IV medication to a client and accidently 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 biohazardous material spill? Doxorubicin hydrochloride Ampicillin sodium Metronidazole Phenytoin132. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? Obtain the newborn’s body temperature using a tympanic thermometer. Assess the newborn pain level using FACES pain scale. Auscultate the newborn’s apical pulse for 60 seconds. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. 133. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? “Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3 mg Subcutaneous every 4 hr PRN for pain “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” “Morphine 3 mg SC q 4 hr. PRN for pain.” 134. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the medications? Calcium gluconate Sodium bicarbonate. Potassium chloride. Magnesium citrate 135. A nurse is reviewing the formulary about NPH insulin before administering the medication to a client. Which of the following information the nurse expect ? Administrer NPH Insulin 30min before breakfast. Give NPH Insulin by IV bolus Use NPH insulin to treat ketoacidosis Discard the NPH insulin vial if the medication is cloudy 136. A nurse is planning care for a school age child who is 4 hr postoperative following appendicitis .Which of the following action should the nurse include in the plan of care ? Administer analgesics on a scheduled basis for the first 24 hr Apply a warm compress to the operative site once daily Offer small amounts of dear liquids 6 hr following surgery Give cromolyn nebulized solution every8 hr 137. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the fetal well being due to potencial preterm labor following places of equipment should the nurse use to evaluate the fetal heart rate? Intrauterine pressure catheter Spiral electrode Toco transducer ultrasound transducer138. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer. Which of the following findings should the nurse identify as a contributing factor? The client takes prednisone for arthritis. The client is receiving IV dextrose 5% in water at 100 mL/hr. The client has a total cholesterol level of 190 mg/dL. The client has an albumin level of 3.8 g/dL 139. A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The nurse should monitor for which of the following adverse effects? Hypoglycemia Hypokalemia Euphoria Increased intraocular pressure 140. A nurse is providing discharge instructions about newborn safety to a client who is 2 days postpartum. Which of the following instructions should the nurse include? Change smoke detector batteries every other year. Lay the baby on his stomach to nap during the daytime. Use a car seat when traveling by airplane Place a plastic waterproof sheet over the crib bedding. 141. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass surgery .which of the following finding should the nurse impact in the affected extremity? Cool extremities Pedal pulse of 2+ Throbbing pain Capillary refill of 4 seconds 142. A home health nurse is teaching a new parent about caring for his 1-week-old-infant. Which of the following statements by the client indicates an understanding of the teaching? “I can use a form pillow to prop up the bottle when feeding my baby.” “I will avoid picking up my baby too often to keep from spoiling him.” “I will hang a pastel-colored mobile 24 inches above my baby’s crib.” “I will place a ticking clock nearly to soothe my baby throughout the day.” 143. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? Apply zinc oxide ointment to the irritated area. Wipe stool from the skin using store bought baby wipes. Wipe urine from the skin using a cool cloth Apply talcum powder to the irritable area 144. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should identify that which of the following allergic reaction to this medication ? Difficulty swallowing Blurred visionWeight gain High blood pressure 145. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? Place the tip of the thermometer under the center of the infant’s axilla. Pull the pinna of the infant’s ear forward before inserting the probe. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. Insert the thermometer in front of the infant’s tongue. 146. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? CC. Coffee with creamer. DD.Lettuce with sliced avocados. EE. Broiled skinless chicken breast with brown rice. FF. Warm toast with margarine. 147. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 148. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? Chest pain Muscle spasms. Cool, moist skin. Incisional pain. 149. A nurse is providing teaching to a client who is to begin external radiation therapy for cancer .Which of the following information include ? Wash your skin thoroughly with a washcloth after each treatment Wear a binder over the radiation site You might experience altered taste sensations Use rubbing alcohol to remove the ink maricings 150. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following intervention should the nurse take ?Suction nares prior to feeding Request a prescription for guaifenesin Administer palivizumab intravenously Initiate neutropenic precautions 151. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is therapeutic? “Can you talk about what happens with your partner at home?” “Why do you think your partner’s symptoms are progressing so quickly?” “You should make sure your partner takes the prescribed medication.” “You did the right thing by bringing your partner in for treatment.” 152. A nurse in a provider’s 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 notifiable infectious disease that should be reported to the state health department? E. Chlamydia F. Human papillomavirus G. Candidiasis H. Herps simplex virus 153. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist? The client’s parent is in a skilled nursing facility The client is allergic to penicillin The client has two small children at home The client lives in a two-story home 154. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hr-intake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take first? Compare the client’s wight to the previous day. Reduce the client’s sodium intake. Encourage the client to change positions frequently. Administer furosemide to the client. 155. A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 monthsA client who will be receiving her first ECT treatment today A client placed in restraints due to aggressive behavior A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety 156. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. which of the following actions should the nurse take Decrense the lighting levels in the nursery Wrap the newborn loosely in a bianket Encourase frequent eye contact with the newborn during feeding Provide frequent stimulation for the newborn [Show More]

Last updated: 2 years ago

Preview 1 out of 63 pages